As Canada moves toward 3-year training for family doctors, some worry about worsening shortages
College says physicians need exposure to complex cases; others say it will exacerbate an already short supply
The College of Family Physicians of Canada (CFPC) wants to increase the length of family medicine residency from two years to three as a way of preparing doctors for more complex patients. But the plan is raising concerns it will increase the shortage of family doctors at a time when six million Canadians don't have access to one.
Residency is the clinical specialty training that new physicians must do after they obtain their medical degrees; they can't practice without completing it.
The first three-year program is expected to roll out in 2027, said Dr. Nancy Fowler, a family physician from Hamilton and executive director for the CFPC's Division of Academic Family Medicine, the national body that establishes standards and accredits postgraduate family medicine training for all of Canada's 17 medical schools.
"Family doctors, in particular, as the front line of health care … are really facing a changing picture in terms of an aging population, social complexity, unprecedented levels of concern about addiction and mental health," Fowler said.
"[They] also find themselves under-supported when it comes to running their practices and the administrative supports required."
According to Fowler, the college did consultations with established family doctors, medical schools, students and residents, as well as looked at programs in other countries, to conclude two years is not enough time to learn the core skills, plus subjects such as elder care, new technologies and virtual care, mental health and addictions, and the health effects of racism and colonialism.
The first goal is to broaden the base of training and exposure so family doctors will be equipped to work anywhere in Canada — from cities to northern and rural areas, she said.
There is also a need for new and strengthened skills in specific areas of health care, learning about virtual care and artificial intelligence, and working with other health-care providers in teams, she said. Many family doctors also need to learn how to set up a practice.
"It's really not in any way an indictment of current training; it's just more we need to keep up with the times and we need to make sure that our training kind of evolves," Fowler explained.
At two years, Canada's family medicine residency is one of the shortest in the world, although new physicians have already completed a qualifying undergraduate degree and their medical degree — about a decade in school.
Most European countries select doctor trainees out of high school; medical school then lasts six or seven years, before the new physician completes a residency.
Australia, New Zealand and Ireland offer five-year family medicine training after an MD.
Meanwhile, educators in the United States are looking at moving from three- to four-year residency programs for family physicians.
Pilot projects south of the border have found a longer training program attracts students who say that extra training gives them the confidence to practice full-scope family medicine, Fowler said. Some U.S. surveys show one-third of medical students and nearly half of family medical residents expressed interest in a fourth year.
Fewer med students may choose family medicine
Opponents to the plan say it is more than just an academic debate; it has direct implications for patients and health-care policy — and at a time when one in five Canadians don't have access to a family doctor.
What's more, fewer Canadian-trained medical students are considering family medicine as their No. 1 choice. Some medical students and resident doctors say the shift will make the specialty less attractive.
Dr. Zeke Blumenkrans first spoke to CBC News in May, when he was two months away from finishing his two-year family medicine residency at the University of Toronto. He said he didn't think the extra year made sense at a time when so many Canadians don't have access to a family doctor.
"I feel like I'm quite well prepared. And I also feel like I have the drive to look up anything that I don't understand and the motivation to make sure that I do what's best for my patients — and, to be very transparent, if I'm uncomfortable in a situation, to ask for help," he said.
CBC News checked in with Blumenkrans again in August, after he had spent the summer working at two remote fly-in First Nations, an addictions clinic, homeless shelter and a community health centre in Toronto.
He was, if anything, more convinced that two years of residency is sufficient.
"I don't think anything can really prepare you for independent practice. It doesn't matter how many years of residency or fellowships you do, it's a whole different beast," he said. "With that being said, I felt incredibly well supported by my colleagues."
Blumenkrans was initially torn between family medicine, pediatrics and internal medicine. But he said he might not have chosen family medicine if it had been a three-year program.
"One of the big things that drew me to family medicine is … the breadth of the practice. The fact that I could do addictions, I could do palliative, I could do sports medicine, I could do obstetrics — all within family medicine, with a bit of additional training if needed," he said.
"It's half the length of the pediatrics residency.… For someone who's finishing his 10th year post-secondary, that was quite appealing to me. And also as an opportunity to start paying off my inordinate student debt."
Blumenkrans understands the college's argument that patients have more complex needs than ever, and family physicians need a wider breadth of understanding and training to match that. However, he points out there is already an option of adding an extra year to learn specialized skills, as well as continuing education opportunities.
Blumenkrans also said he knows the COVID-19 pandemic has also taken an enormous toll on family physicians — between burnout and morale, many are ready to retire.
"Do I think that now is the time for us to implement an additional barrier to people pursuing a career in family medicine? Not really," he said, noting that all of the physicians he's worked with have a strong interest in making sure new doctors don't get overwhelmed as they begin their practices.
The Canadian Federation of Medical Students (CFMS) and Resident Doctors of Canada (RDoc) have also come out in opposition to the plan.
"We support the curricular revisions and renewal of family medicine residency programs to adapt to the changing realities of primary care in Canada, including interdisciplinary care. However, our organization does not support the recommendation that involves lengthening the training program from 24 months to 36 months for all candidates," CFMS said in a statement.
"As a student organization aiming to aid in solutions to overcoming the primary care crisis and to promote Family Medicine, we are concerned that this increase in program length will drive more students away from family medicine as a career choice."
The overwhelming message from current family medicine residents is that an extra year would be a "massive deterrent" to pursuing the specialty, said Dr. Devon Mitchell, RDoC president and a fourth-year emergency medicine resident at the University of British Columbia.
RDoC "cannot support any extension of training" in the absence of a "well-defined, well-rationalized, evidence-based reason," Mitchell said, noting RDoC has seen preliminary survey data that suggests 42 per cent would reconsider their decision if training were extended to three years.
"What we're looking for is specific objectives that are easily quantifiable, easily measurable — and also proof that those objectives are not being met under the current training model," he said. "If our residents feel that the training is not providing them the tools they need to be good family physicians … then we're all for it. But right now, we haven't seen that evidence."
'It's a foreseeable disaster'
The plan is also getting push-back from some doctors, including representatives of rural and emergency medicine organizations, who worry about what it might mean for already under-serviced communities.
Dr. Sarah Giles is a family and emergency physician in Kenora, Ont., who also teaches at the Northern Ontario School of Medicine University. She worries decisions are being made without studying how residency training is working for doctors in rural placements, which have a much broader scope of practice than their urban counterparts.
"The College of Family Physicians says they want family doctors to come out of their residency being competent to deliver babies, run an emergency room, look after in-patients, deal with addictions, be culturally competent in different environments — and we find that our rural residents are able to do that because we do it all every day," said Giles.
"I think we need to say: What are the core competencies that we need? What can we learn from our rural sites? How do they do it differently? How can we encourage our existing preceptors in urban areas to do more?"
She's also concerned longer training could further exacerbate acute shortages in both family and emergency medicine in smaller communities, as many rural family doctors also staff local ERs and see patients on hospital wards.
Giles sees the plan as effectively eliminating a full year of family medicine physicians.
"That is a disaster," she said. "And not only is it a disaster, it's a foreseeable disaster and it's an unnecessary disaster."
'We can't have a gap year'
Fowler acknowledges that concern, stressing the change won't roll out across the country all at once.
"We can't have a gap year," she said. "We are envisioning a slow, gradual and incremental change."
The CFPC is doing cost-modelling, feasibility assessments and in conversation with both the federal and provincial governments, Fowler said, with hopes of having provincial funding commitments finalized by March 2024.
Ultimately, Fowler said, this is part of the college's efforts to help fix the crisis in family medicine, which includes fair pay for family doctors and supports to lessen the administrative burden.
Meanwhile, the College of Physicians and Surgeons of Ontario has suggested a shorter family medicine residency as one way of easing the doctor shortage.
In an August 2022 letter to the Ontario government, the CPSO suggested "exploring the re-introduction of a limited class of registration for general practitioners, along with changes in residency programs, to enable residents to get into practice sooner — with the option to re-enter specialization training at a later date."
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