Building the coffin for 'cradle to grave care': An opinion on the CFPCs Outcomes of Training Report

Comprehensive Family Medicine has often been described as providing ‘cradle to grave care.’ However this very concept is now under threat—externally, and now internally. Through a well-intentioned but short-sighted report with opaque external consultation the College of Family Physicians of Canada (CFPC) has failed and stands to limit its future members potential. The report fails to recognize the very challenging and changed work environments for family physicians practising comprehensive care as the proximate cause for the death of general practice. The length of training programs is not the disease, but the clinical work environment that is the pathology. The diseases of increasing administrative work, lack of national licensure, burdensome overhead costs, and erosion of clinical independence and primary care leadership are the areas that the CFPC could instead spend their time advocating for solutions. The first recommendation of the CFPC’s Outcomes of Training Report (OTR) announced in January 2022 that it intends to extend residency training in Family Medicine to three years. Though the report states that “residency program leaders and residents affirm the need for additional training time to consolidate skills in acute care and procedural domains,” the evidence for this is “inadequate to properly evaluate the impact of our graduates in the healthcare system.” But this conclusion is very different from the hundreds of comments that have surfaced after this announcement. Nearly 100 replies to this topic were posted by readers, most of which raised concerns about the report’s conclusions. As well, we solicited feedback from our private Facebook network of over 1,500 Canadian Family Medicine residents and early career physicians. One of the most common concerns was that the increased length of training, separating medical students another year from a physician’s salary, would discourage their choice of Family Medicine as a career “I believe this will result in a drop off of applications to fam med programs,” said Dr. Ramunas Saplys. “Students will look at one extra year to do a gen med residency and opt for that unless they plan a rural practice.” The report purports to have listened to educators who clearly state the curriculum is full and that more of the same is not the solution. They quickly then fall on the crutch of a uniform increase of residency length without recognizing that within a competence-based framework that longer is not better—quantity does not trump quality. While I agree with the overarching intent in the OTR report to graduate the pluripotent Family Physician, the failure to recognize the developing external market forces into which graduates are taking their first tentative steps after residency is a gross oversight, and frankly harmful on a number of levels. Many early-in-practice physicians are often encumbered by large debt loads. The simple addition of one year of residency will lead to a conservative estimate of $100,000 of lost lifetime earnings, and with a simple 6% compounded interest rate over 40 years that works out to $1,095,745.37 of future value. While one hopes the CCFP understands that increasing the training duration for all FPs to that of an Internal Medicine residency would also mirror remuneration rates for those specialists—I think we can safely surmise those who hold the provincial purse strings won't make that leap as readily. One has to wonder what the cost implications are to stringent university and provincial budgets as well, which the report unfortunately simply doesn't address. Further, what are the cost implications of the recommendations to the organization? And the multitude of committees, task forces and work that will be funded through membership fees? Are we going to see increased fees to be CFPC members in order to support this ill-thought-out and purportedly virtuous change? This potential change is a challenging burden to bear for future parents, planning families and future living arrangements, while completing residency for another year. The lack of any gender-based analysis in the report is a striking failure. While it states there was extensive research/consultation, all of that consultation is kept confidential. That should concern all who pay dues to the organization. We only have to look at the changes that were unilaterally implemented (and then reversed) by the CFPC Board Examinations Committee to the Emergency Medicine exam last year (without any consultation) to see a past example of how the national organization failed to consult with relevant stakeholders in the recent past. In a poll conducted by The Medical Post, 67% of respondents indicated that Family Medicine training should not be extended. Fewer FPs are providing comprehensive primary care at this time, which was cited as a reason to support the increase in training length. In fact, the OTR cites that only 50% of early-career FPs provide comprehensive care in two or more clinical settings. However, in the same report, the primary reason listed is “lack of personal interest” and not length of training or perception of personal competency. “The thinking is that a three-year residency will increase the ability of FPs to do comprehensive care” says Dr Barry Birosh. “However, it is unlikely that more FPs WANT to do comprehensive care.” When we step back and consider that one of the major factors leading to burnout is lack of autonomy and decision making ability - the main outcome of the report will take away the autonomy of completing residency from soon-to-practice family physicians. Comments strongly favoured increasing the quality of training to meet societal needs, but not necessarily the length. Others proposed options to meet the growing complexity of primary care; for example, Dr. Peter Loveridge suggested eliminating the need for an undergraduate degree before medical school. Dr. James Stephenson suggest a formalized mentorship process for new graduates rather than longer training. When considering the rising need for rural full scope FPs, in an already underserved population, the report fails to clearly articulate how another year would serve to help this group. The CFPC states a broad group of stakeholders were consulted throughout the creation and the development of the report. But who? Where are the names of the key informants, expert panels and partner organizations? Those consulted are never listed and we see nothing from the SRPC or CAEP as two major organizations representing cornerstones of Family Medicine in Canada. A shift to a mandatory third year won't allow those planning to focus practice in Emergency Medicine, for example, to complete their training in three years. We've heard no concerns from those three-year graduates about their competence and comfort in practising in their fields? While we agree that building and graduating competent, world-class leading FPs is essential to the success of our healthcare system, the OTR fails to see the forest for the trees. They have chosen a blunt instrument that will fell the trees and harvest the wood for the coffin of General Practice training in Canada. I hope the following suggestions will be taken into account as the CFPC cuts a path that's currently unclear and fails to recognize the real obstacles in its way. The obstacles they're placing on the future practitioners of Family Medicine without cause and with weak evidence leave more losers than winners. Instead of extending all residency programs to three years, the CFPC allows resident physicians to choose either a two or three year program. Residents have the right to choose the content of their third year so it is most relevant to their practice. Residents have the option to write ANY existing R3 certificate of added competency exam (e.g. palliative, anaesthesia, emergency) at the end of their third year of training as long as existing educational requirements for those certificates are met. Remuneration for residents in a third year of residency should be proximate to the level of care they are providing. Remuneration for Family Physicians after a three-year residency should be equivalent to remuneration for other specialists who complete a three-year residency prior to implementation of the residency program. Full budgeting of the entire program including consultants/task forces for the next five to 10years and impact on CFPC fees along with the full cost of production of the OTR report. We all look forward to active and open discussion about this foundational proposed change to the educational landscape for Family Physicians in Canada. I hope the CFPC will disclose all discussions and documentation that led to this report and allow for wide stakeholder input that is received, accepted, and actioned - not as a fait accompli but as an honest look to the future of training in Family Medicine. Dr. Paul Dhillon is a rural GP in Sechelt, B.C.

Building the coffin for 'cradle to grave care': An opinion on the CFPCs Outcomes of Training Report

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