Pride and prejudice: The future of general practice in Canada

The debate on the future of family practice in Canada is of the utmost urgency; it cannot be delayed until the next iteration of the Canadian Resident Matching Service returns yet another dismal result.

Dr W.W. Rosser, professor and chair of the Department of Family Medicine at Queen’s University, poses the following question: “Why would anyone choose a medical career with an excessive workload, an unclearly defined role, information overload, and the lowest pay?”[1]

This question can only be answered through rapid and open debate in the halls of medical schools and government buildings across Canada. The outcome of this debate and, indeed, its very occurrence, is of special significance to me, as I am embarking on the career path to which Dr Rosser refers; I am studying to be a family doctor. The glaring failure of the Canadian Resident Matching Service to consistently fill family practice residencies threatens the existence of the Canadian health care system in its current form. The question thus arises, can the Canadian health care system be expected to function in another decade if the current trend of unfilled family practice residencies continues?

Relevance

Both federal and provincial governments must work toward finding a solution to the lack of family doctors today, and the impending shortage in the future. Countless polls have shown that the majority of Canadians believe that accessing publicly funded family doctors is of primary importance. It is thus imperative that governments at all levels work to preserve and replenish the system that guarantees access to family physicians to all Canadians.

Further evidence of the importance Canadians place on their family doctor in health care provision was provided by polling results released in late 2003. Thousands of Canadians were polled in a survey commissioned by the College of Family Physicians of Canada (CFPC). It was found that “most Canadians identify their family doctor as the most important person to the health care of themselves and their families.”[2] The same poll, however, found startling evidence “that 14 percent of Canadians—or 4.2 million people—still report not having a family doctor, a factor seriously jeopardizing their ability to access quality care in the community and in the hospital.” Although some of these people may choose not to have a family physician, a visit to most doctors’ offices will find that the offices simply can’t handle increasing their patient load by taking on new patients. The CFPC president at the time of the poll, Dr Peter MacKean, believes that family doctors are “the backbone of Canada’s health care system,”[2] If this backbone breaks, our health system will break also.

The CFPC publication Primary Care and Family Medicine in Canada: A Prescription for Renewal further highlights the importance of primary care, asserting that “as a society, Canadians must be assured of access to high-quality primary care both today and in the future.”[3] It is only through actively recognizing the importance of the family doctor in medical institutions and as a society that we can assure this future. This can only be achieved through recognition of the essential role medical schools play in determining the form of the health care system in years to come.

Fraternity

Close examination of the social and academic environment in which young doctors are trained tends to be greeted with a degree of skepticism. The emphasis seems to be on specialization, rather than on the perhaps more humble—and less lucrative—pursuit of family medicine. If statements made in the CMAJ by students in Canadian medical schools are any indication, family medicine ranks very low on the medical specialty ladder.

In a letter to the editor, Dr Kuljit Sajjin wrote, “throughout my medical school training, family medicine was looked down upon as a career [at UBC]… [Once] I began my medical education I did not receive any encouragement to pursue this path until I actually spent time in a family practice elective. Unless attitudes toward family medicine change in our academic training centres, we can expect an American style system, where specialists outnumber family physicians. Perhaps then a better appreciation of primary care will emerge.”[4] These sentiments were echoed across the country by a past president of the Canadian Federation of Medical Students (CFMS). Dr Danielle Martin heard belittling comments about the academic skills needed for family medicine during her clerkship year: “one of my preceptors said I was way too smart to be a family doctor.”[5] Even if students enter medical school with the intention of specializing in family medicine there may be social factors, in the form of deeply rooted preconceptions and the resulting commentary by members of the medical fraternity, that influence them to change their direction. Dr Matthew Erskine, another past president of the CFMS, writes, “not only is the formal curriculum, with varying degrees of exposure to different types of family practice, important, but so too is the unwritten curriculum students are exposed to as they undergo socialization in the fraternity of medicine.”[6]

Generalist vs specialist

The perceived lack of respect afforded to general practitioners is only one of the causes behind the falling numbers of family practitioners. There seems to be an additional underlying assumption that because you are a general practitioner, your clinical knowledge is inferior to specialists. However, family physicians have to be able to use their broad knowledge and apply it to the many specific cases that walk through their doors.

Dr Claude Renaud, former director of Professional Affairs at the CFPC, believes that the “glamor of the subspecialties” is overshadowing general practice.[5] Rosser states that “most medical students buy into the myth that family medicine is an amalgam of all specialties and is impossible to practise competently given the overwhelming information load.”[2] Dr George Goldsand, a former dean of postgraduate medicine at the University of Alberta, believes that “many people are very concerned about trying to remain current in such a vast field.”[7] It is because of this that the tendency to subspecialize is so appealing. One cannot forget, however, that no matter how appealing subspecialties might seem to the doctor-in-training, most Canadians don’t feel that their surgeon is the best person to look after their overall well-being—family doctors still come first. Our medical system relies on an even mix of generalists and specialists, so family doctors are an essential part of the medical system. Dr Renaud explains that “if we were to lose the balance we have, the system won’t function...we need the gatekeepers.”[5]

Où sont les gardiens?

So where are the gatekeepers going to come from? Or is the future of Canadian medicine one that is without gatekeepers? Recently, Halifax internist Sander van Zanten said that “we are heading for a crisis in general care” because of the problems in recruiting future family doctors from the residency match.[7] The recent results are startling and indicate a downward trend in the percentage of students interested in family medicine. “After the first round of the 2003 residency match was completed February 27, 139 of 484 training positions in family medicine—29%—remained unfilled, with one-third of the 36 programs filling 50% or less of their openings.”[5] Following these dismal results, “in 2004, there were 124 unmatched family medicine positions in the Canadian Resident Matching Service’s (CaRMS) first iteration. After the second iteration, 29 positions remained unfilled.”[8]

This trend will surely not continue forever and can be assumed to level off in the near future, but it has already fallen too far to sustain the health care system. Dr van Zanten warns that “the fallout from general medicine’s declining prestige will be felt throughout medicine, but particularly in community hospitals where generalists handle most patient care.”[7] There have been some initiatives at the provincial level to deal with this problem, but the results of a recent study on medical student career choices don’t hold much promise, and the results are more troubling than soothing.[8] The study found that “only 20% of new medical students participating in the study considered family medicine as their first career choice.”[8] This information, along with the knowledge that “there already exists a serious disconnect between the number of available training positions in family medicine and the number of students willing to pursue such a career”[8] is troubling. Although this study examined only a limited number of western medical schools, the results, if they do prove true, do not bode well for the future of family practice in Canada. As the report posits, “should the percentage of students interested in family medicine as a first career option prove to reflect family medicine career preferences at graduation and across Canada, serious implications exist for the sustainability of our present health care model, which is based on access to a primary care physician.”[8]

Consequences

The executive director and CEO at the CFPC, Dr Calvin Gutkin, believes that if we accept the low number of family practice residency spots currently filled each year we are “accepting that the whole system has to change. And if we fall further, it will have a significant impact on the population.”[5]

The CFPC publication A Prescription for Renewal stated that “there is an urgent need for a substantial increase in the number of trained family physicians in Canada.” As we know, doctor shortages are now a pressing problem in many communities. Yet “Canada is presently producing approximately 285 fewer family doctors a year than it was in the early 1990s.”[3] If we want to continue to maintain the level of health care in Canada that we currently enjoy we must take these studies into account, acknowledge the frightening future forecast by these studies, and take action.

Changes and the future

One of the most simple and practicable recommendations was made, not surprisingly, by the CFPC. Simply, “all stakeholders in the Canadian health care system should recognize the value placed by the public on the role of their family doctors, including the care they provide in hospitals.”[2] This issue is addressed through greater awareness and the growing realization of the importance of the family practitioner once again in society and governmental organizations.

Recent changes in the medical school structure in BC also seem to be steps in the right direction. The distributed medical education program that began in September 2004 through a partnership of UBC, UNBC, UVic, and the provincial government is a welcome adaptation of the existing system. However, the fact that all three openings for family practice programs in Prince George were left open in the 2003 CaRMS’ first iteration suggests further issues remain unresolved.[5]

While giving BC medical students experience delivering babies in Trail may be a wonderful experience, the question of whether it will actually produce more family doctors in rural areas is another question. With the expansion goals set at 256 students in the first-year class by 2010, one can be assured there will be more family doctors exiting the medical education system, but will it be enough to keep up with the increased demand? Even with financial incentives provided by the BC government, there still exists the possibility of having a drought of family physicians in rural BC.[9]

An idea put forth by B. Wright and colleagues is that “medical students might have to be selected, in part, because they want to be family physicians.”[8] Perhaps further examination is needed of this idea. The selection processes used by the universities to screen the hundreds of eligible applicants that apply each year are not the most transparent, and perhaps they need to be examined and opened up to the scrutiny that would allow one to examine their impact on the choices that the future doctors will make in their residency choices. This is perhaps a drastic measure, but one that must be examined in light of the societal role that medical schools play in the future delivery of medical services.

In Wright and colleagues’ study, “several factors appear to drive students toward family medicine, most notably having a societal orientation and a desire for a varied scope of practice.”[8] With the current 50/50 split between academic results (quantitative) and the non-academic (qualitative) being the determinants to grant interviews for admission purposes in BC, perhaps the university needs to examine more closely how it interprets the non-academic information in order to look for a greater societal orientation and the desire of the students for a varied scope of practice. “Nationally planners have some thinking to do on policies to address this,” says Sarah Banner, the executive director of CaRMS. “This is particularly true now that national groups are calling for a 50-50 split between family medicine and specialties.”[10] It is now up to the provinces to experiment with policies that will help ameliorate the dearth of family physicians in their respective provinces and then share these practices with other provinces in Canada.

“Hospitals are a vital part of every community… and family physicians are the essential link between the community, the people of that community, and the hospital. Patients and hospitals need family doctors to ensure continuous quality care and efficient use of resources,”[2] says Dr Calvin Gutkin of the CFPC. With the impending shortage of family physicians and the time it will take for policies to be implemented, tested, and reworked, what is a short-term viable solution for the shortage?

In the short-term, Canadians who have gone abroad to study medicine in countries such as Ireland and Australia should be encouraged to return to Canada to practise family medicine, although care must be taken that the returning students are of the same standards as the physicians here. This is an excellent method through which to increase the number of family physicians in Canada without having to increase the infrastructure and financial burden on the provinces. Each year, hundreds of Canadians trained in Commonwealth countries choose to do their residencies in the United States because in Canada they are lumped together with all foreign medical graduates, and are not allowed to participate in the first round of the residency match. Currently “only Alberta and Newfoundland welcome all foreign-trained Canadian medical graduates.”[11] This must change. Allowing international medical graduates to participate in the first iteration of the CaRMS program with family practice as one of their top options would partially ameliorate the problem of empty family medicine residency positions across the country.

After the rough world of medical school has been completed and young family doctors begin their work, it is important to recognize why they do what they do. Dr Rosser puts some context around the satisfaction that doctors will have in a family practice. “Family physicians define and nurture their own scope of practice on the basis of community needs and their own interests in medicine. The role of patient advocate and the interpreter of medical information to optimize each patient’s quality of life provides family physicians personal enrichment. Building a trusting relationship with people through their lives will continue to make family medicine a particularly rewarding and satisfying career choice.”[1]

Hopefully, with some changes being proposed from within the medical system and on a larger governmental or societal basis, this looming threat can be averted and we can continue to enjoy excellent health outcomes within one of the world’s best health care systems.

Seeing that family medicine is my future career and life, after all these dark words about the future of family medicine, it is important to remember the words of Dr David Tannenbaum, program director at the University of Toronto. “[Family medicine] is a tremendous career . . . we just have to get that message out.”[6]

Acknowledgments
I thank Erika Honisch for critical comments on this paper.

References

1. Rosser WW. The decline of family medicine as a career choice. CMAJ 2002;166:1419-1420. PubMed Citation Full Text
2. The College of Family Physicians of Canada. New poll: Canadians say family doctors most important to their health care and want them by their side in hospital. http://www.cfpc.ca/English/cfpc/communications/news releases/2003 10 23/default.asp?s=1 (23 October 2003; retrieved 11 July 2004).
3. The College of Family Physicians of Canada. Primary Care and Family Medicine in Canada: A Prescription for Renewal, 2000. www.cfpc.ca (4 October 2003; retrieved 11 July 2004).
4. Sajjan KK. Just a family doc. CMAJ 2001;165:13. PubMed Abstract Full Text
5. Sullivan P. Family medicine crisis? Field attracts smallest-ever share of residency applicants. CMAJ 2003;168:881-882. PubMed Abstract Full Text
6. Sullivan P. “This is brand new for us”: FP residencies go begging as match ends. CMAJ 2002;166:1449. PubMed Abstract Full Text
7. Sullivan P. Internists worried as concern about general medicine’s future spreads. CMAJ 2003;168:1032. PubMed Abstract Full Text
8. Wright B, Scott I, Woloschok W, et al. Career choice of new medical students at three Canadian universities: Family medicine versus specialty medicine. CMAJ 2004;170:1920-1924. PubMed Abstract Full Text
9. UBC Faculty of Medicine. Admissions, 2004 Statistical Summary. www.admissions.med.ubc.ca/admissions (retrieved 10 July 2004).
10. Sibbald B. Canada’s new doctors turning backs on family practice. CMAJ 2000;162:1347. PubMed Citation Full Text
11. Carey E. Red Tape Deters Needed MDs. Toronto Star. www.thestar.com (12 July 2004; retrieved 12 July 2004).

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Paul Dhillon, BA

Mr Dhillon is a Canadian first-year medical student at the Royal College of Surgeons in Ireland.