The 3-year FM resident: How the CFPC is failing their CanMEDS competencies

Medical expert (the integrating role) At the recent Society of Rural Physicians of Canada conference—one of the first to allow multiple organizations leaderships to meet in person—I was one witness to one of the most intellectually vapid defences of the College of Family Physicians of Canada (CFPC) Outcomes of Training Project that plans to implement a three-year residency in family medicine in Canada by 2027. It was refreshing to be able to actually sit next to colleagues and hear from Resident Doctors of Canada (RDoC) and Canadian Association of Emergency Physicians (CAEP), face-to-face, about the lack of consultation and input they had into this paradigm shifting decision in family medicine (FM) training in Canada. One would have hoped that the CFPC would have really taken on that “integrating role” and would not point to a single 200 person meeting, names of participants and invitees unknown, that was the crucible from which this decision was made. Throughout the conference, discussions and hallway conversations persistently revolved around the shocking future program of the CFPC's outcomes of training program and lack of thought to the rural implications and possible downstream unintended consequences. Read: Dr. Paul Dhillon: Building the coffin for 'cradle to grave care': An opinion on the CFPCs Outcomes of Training Report Scholar This OTP report believes, and purports to provide the evidence for, movement to a three-year FM residency in Canada as a part of the band-aid solution for all that ails FM in Canada today. The report states that “the CFPC presents evidence-informed educational recommendations focused on the residency training profile as a shared vision of the future.” However, the evidence is clearly either lacking, weak, or applied across countries and contexts. As a scholar you cannot leap, without accompanying incredible mental gymnastics from: “Strong evidence is generally lacking on the ideal length of FM residency training, hence the reliance on original research articles from the United States. Many of the studies have small sample sizes, are region-specific, or sample residency programs that are more competitive, potentially skewing performance outcomes and results.” And, “the transferability of research may be somewhat limited across these jurisdictions.” And, “The major finding of this study was that no single database exists that provides all the desired information describing the characteristics or demographics of family physicians, what they do (related to the FMPP),and where they practise (geography). Moreover, even if we were able to combine available databases, major data gaps would still exist.” Simply put, a “rapid literature search,” that finds no Canadian studies to support a dramatic change in training, is not robust evidence, it is a rapid search that found no Canadian evidence or clear impetus for change other than self-referencing a number of CFPC reports. This would never muster passing any modicum of peer-review and in fact looks more and more to be dense hubris. Any evidence that additional time in training would increase the comprehensiveness of practising FPs is clearly lacking. If there was evidence that increasing training would do that—it would not magically have fallen on exactly a third year—there would have been an evidence-based answer to “how much more training time is required to complete these competencies in order to provide more comprehensive care to Canadians.” When pressed for evidence to support this decision, Dr. Brady Bouchard, CFPC president, instead provided the anecdotal personal experience of a single trainee: himself, saying he did not feel ready. Why has this replaced the opinion of the hundreds of future graduating trainees? It is in fact shockingly duplicitous to see the organization come out with a paradigm shifting change to FM education with so little discussion and consideration of the potential unintended consequences of this action. The CFPC president could not even name one possible unintended consequence of the OTP. The minutes of the meeting where this decision was (hopefully) rigorously debated would be enlightening. Professional It is clear now that the CFPC will not accept any of the additional certificates of added confidence to be completed in place of this mandatory third year of training. Welcome to de facto four-year GP-Anesthesia & EM programs—changing the decision tree of graduating medical students. This has the potential to drive medical students away from FM. Trainees will not choose FM when they can complete a FRCPC designation and the resultant pay increase. Let us not forget the simple math and future value of paying off loans and investing early in a career. The college states that the third year will “not be more of the same.” But where is the plan? The obvious lack of planning, evidence and forethought is disconcerting. Collaborator & communicator It’s odd that we haven’t seen a single joint statement of support from the plethora of organizations that are a part of the educational ecosystem of FM training in Canada. Governments? We’ll approach them after. Residents? Well their organization is opposed. I wonder if the pandemic allowed an insular policy to blossom into an untamed flower that should have been cut and trimmed with input and discussion over the pandemic. The timing is perfect for reform yet the CFPC is taking a step in the wrong direction. The current rate of public dissent, media coverage and legislative discussions surrounding the primary care crisis is the loudest it has been in decades, signaling that FM reform is possibly just around the corner. Physicians can be a part of the solution, or they can have a government solution imposed upon them. Now is the time for the CFPC to lead the charge by representing its members for real reform that benefits physicians and patients, not diving head first into defending a ridiculed and meritless FM residency extension that will only exacerbate the crisis—and more so in rural Canada. Health advocate & leader As was pointed out in Ottawa directly to the current president, family physicians are not working 24/7 anymore they are working 36/8. More administrative burdens and external challenges to the practice of FM have never been extant and so apparent. In this extremely challenging external environment the CFPC somehow came to the conclusion that a third year of FM training would be a part of the solution. Instead the 200 colleagues and family physicians that were involved have, I believe hastened the decline of FM as a desired specialty in Canada. One of the most thoughtless arguments I have heard is that Canada has the shortest FM training program in the world. What they fail to recognize is that by moving to three years we would still be the shortest FM program in the world, we would just be equivalent to the United States. The college states very clearly at the beginning of the report that the two-year residency creates competent family physicians. However they have somehow made an intellectual leap that comprehensiveness in practice is related to the duration of residency where it is far more likely related to the external environment and personal or intrinsic factors in the resident body. The study points out that FM graduates are predominantly female, average age of 33 and that greater than 50% of all residents are expecting or having children in the near future. How does a third mandatory year affect them? The report is silent. They fail to see that it is personal factors and external factors not the duration of training that have caused this crisis and are adding another nail in the future of FM’s coffin with this project. Leadership is owning up to your decisions and making decisions with information. I urge the college to share the discussions around budget and annual dues implications, project preparation costs, projected costs of implementation, and probably most importantly the full minutes of the board discussion that led to the approval of this major project alongside who the chosen 200-persons were that attended the retreat. All this should be revealed to the fee-paying membership. Leadership is not only leading forward, it’s also taking a tactical pause and asking: is this the right time, place, and direction for FM education to go right now? Dr. Paul Dhillon is a rural GP in Sechelt, B.C.

The 3-year FM resident: How the CFPC is failing their CanMEDS competencies

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