10 questions about the three-year family medicine program

I am vaguely aware of the ‘three-year debate’ ongoing over decades, vaguely aware that the change is in the works, and acutely aware that many practicing colleagues are alarmed and baffled. These are my own 10 questions on the subject: When does a trainee “feel ready?” I had the BEST two-year program at Victoria Family Medical Centre in London, Ont. in the early '90s. There was exemplary and character-shaping mentorship from teaching doctors, nurses, allied health. It felt like a family. This centre provided in-depth emphasis on psychosocial medicine, something peers ridiculed (in good nature) at the time, but has served my practice so well over the years, especially now. If you asked me back then, if I wanted to stay a third year, I would have said yes! If you asked me back then whether I was ready to practice, I would have said no! Yet as much as I loved that cradle, I had to grow up by leaving it, developing my own practice, finding my own patients. I could not grow up inside a cradle. Are trainees today any different? Will three-year graduates be rewarded? Back then, those of us with two years felt we were more “learned,” since “we” were CCFP and “they” were not. Real world practice quickly equalized the two streams. Will three-year graduates have their due bragging rights? Granted, they will show everyone how hard it takes to train a family doctor of the 21st century . . . “It now takes 3 years!” . . . and press a safe distance from those whom we fear will “replace” future “us.” Let's hope that translates to better prestige, recognition, even better pay for my younger peers. But what if it doesn't reward them in that way? Where are we going to put up everybody? I heard the argument that moving to three years removes a whole pool of graduating family doctors from across our country, at a time of serious physician shortage. Indeed, that's a real math problem, not to mention really bad timing. But I am trying to work out a “real estate” problem. Are there enough spaces in teaching centres to accommodate all the extra people? Or will some accommodate only years one and two, others two and three, and yet others one and three . . . and send the surplus somewhere else? Will this take away from the one on one mentorship crucial in my own training? And if we do absorb 33% more trainees, will we also pony up 33% more supervisor time, and 33% more support staff? Will the family medicine team be more impressive on rounds? For training programs that are lucky enough to have family medicine admitting beds in the local hospitals . . . imagine the parade through hospital hallways, led by staff family doctor, followed by R3, R2, R1, and medical students, impressive like internists and surgeons, finally! I remember making rounds in hospital as a family medicine resident, humbly by myself or in pairs. Despite this exercise, I discovered as I started my practice, family doctors can no longer admit directly to our local suburban hospital. Will three-year skills be more useful? Skills are always more useful when they are used! Three-year residents will sure gain additional skills. Even “two-year me” learned to cast fractures, take out toenails, deliver babies . . . but I just don't like doing them. Although I checked off the boxes, I did not continue these skills after graduation. I preferred counseling, doing home visits, palliative care, and making practice accessible and efficient. Like admitting your own inpatients, it's only useful if future practice environment allows it to happen. If a trainee learns to perform POCUS (point of care ultrasound), but can't afford to buy one, until years later when better tech is available for cheaper, what is really gained? Or if trained to be a “team leader,” but prefers working solo, or not enough teams around to join, what then? Can three years be rolled out with more science, less ideology? Since this third year of training has not been done in Canada (other than special designation in added competency areas), committing 100% family residents to this takes a giant leap of faith. The aspired outcome is that they will come out more confident, committed to longitudinal practices, and lead teams. But why assign 100% to the trial arm of this experiment? If new chemotherapies are not tested this way (for survival rates), why should family medicine residents be? Why not . . . allow residents to choose a two-year vs. three-year program, and compare the two cohorts . . . like how it's done in other scientific experiments? Why not . . . redesign family medicine education like the four + two year Queen's-Lakeridge Health MD Family Medicine Program and see how it works first? Is it OK to not know everything? Every time I make a house call, I am a bit apprehensive. I am out of my “comfort zone.” I don't have the usual references, tools or staff; it demands more my “good sense” skills than medical ones. But I had so many positive experiences in spite of the “have nots.” All my colleagues deal with gaps, and my generation of family medicine residents made peace with that. What message are we now sending to residents? Can two be better than three? “We have the shortest training program compared to U.S., U.K., Australia, and New Zealand”, cites CFPC's report. Why is short a problem? If my factory can make a widget in two days, and my competitors in three, why should I learn from them, and not they from me? The global healthcare human resource shortage is real. Countries that allow their citizens and healthcare providers to thrive will attract talents from other countries who trained those talents. Big investor-oriented private corporations will also woo our graduates to work for them. Have we lost sight of that reality, and while we double down on lengthier education, others are looking to reap our next generation of doctors? What does it really take to make a family doctor? I found the first 10 years in practice really hard, having to face my own personal insecurities. When patients looked down on inexperienced younger me, I resolved, “even if they see me as a second-rate doctor, I am going to treat them as first rate patients!” I thought one could close the gap by thoroughness, being nice, hard work and continuing study. The second decade was really hard too, because I gradually saw the limitations of medical science, even with all its multi disciplinary and biopsychosocial wonders. As Mark Twain puts it, “the physician who knows only medicine, knows not even medicine.” By the third decade, when patients I saw as babies brought in their babies, and I witnessed people live illnesses, face deaths, and all the joys and sorrows life brings in between, I can much better relate to the humanity of my patients, and connect dots in ways I didn't know I could at the beginning of the career. And I suspect I'll still see more and learn more in future years. But none of this could be rushed, in three, four or 30 years. What other questions should we be asking? Your turn, I listen. I hope others will too. Dr. Adam Chen is a solo doctor in Oakville. He remembers, with deep gratitude, his supervisor Dr. Hogg, and the other amazing teachers at Victoria Family Medical Centre: Dr. Haswell, Dr. Brennan, Dr. Payne, Nurses Joanne, Barb, Psychologists Helen, Gail . . . and wonderful fellow residents of 1990-1992. What a formative experience that was.

10 questions about the three-year family medicine program

Register for free access or login.

Related Topics