The CCFP sucks

[brooksbane]

123123123123123123

[futureGP]

Here is a response to Dr. Buchman (last year's CFPC president) published in december issue of CFP

http://www.cfp.ca/content/58/12/1332.full

 

Lawrence C. Loh, MD MPH CCFP

 

As a family physician who began practising relatively recently, I read with some concern Dr Buchman’s President’s Message that called for consideration of lengthening family medicine residency training to 3 years.1 His arguments in support of re-opening the debate about the length and scope of family medicine residency can be broadly summarized as the following: studying family medicine has become more difficult over the decades; fewer family physicians are providing full-scope, comprehensive care; and, simply put, other jurisdictions are doing it, so why shouldn’t we?

 

The first argument presents the logical fallacy that “different is more difficult.” We can concede that family practice today is different. However, calling it more difficult ignores the fact that the broad nature of family practice has always challenged physicians who have made it their calling. Consider that family physicians in 1972 and 1992 did not have nearly as much access to diagnostic, therapeutic, programmatic, and allied health support as family physicians do today. In essence, it is not solely the problems that have changed. There is an armamentarium that has grown alongside; the advent of electronic medical records,2 the Internet,3 multidisciplinary health teams,4 improved patient education, and novel teaching methods all allow today’s family physicians to effectively and efficiently address the new challenges faced by our specialty.

 

Related to this, we must remember that there is no replacement for the practical knowledge that comes from practising in the very environment that Dr Buchman describes. Academic family medicine resident practices are often heavily skewed to specific population groups.5 One questions what would be gained by a third year in such an environment instead of shouldering the full responsibility of a real-world practice. Nothing can replace the valuable lessons I learned during my first year of practice, when it was me on the hot seat without a tether.

 

In his second argument, Dr Buchman correctly states that “many factors contribute” to fewer family physicians deciding to practise full-scope comprehensive care, but highlights his belief that a 2-year residency is “likely ... too short” for residents to gain the confidence and achieve the competencies required to practise family medicine today.1 This could be true. However, anecdotally among my colleagues and I, there are certain procedures that today’s graduating family physicians will never be interested in practising. Indeed, many residents choose family medicine for the sole reason of avoiding surgical or hospital involvement6; others select family medicine because of the flexibility associated with a broad field of practice.7

 

In many cases, avoidance of certain aspects of comprehensive care is more related to a lack of interest than a lack of confidence. If someone is uninterested, they are no more likely to develop these skills by pursuing learning experiences in a 3-year program than they would be after a 2-year program. Competency-based education is more likely the way to go: support those who are interested in specific areas, while ensuring all physicians (including those less interested) at least know the basics. The expectation that all family physicians will practise comprehensive care in all settings and regions of our diverse country unfortunately lies somewhere just short of fantasy. Supporting trainee interests and talents would be more effective in ensuring appropriate allocation of training opportunities and subsequent distribution of human resources.

 

The final argument—that other jurisdictions are lengthening their training time—can be addressed in many ways. Other jurisdictions are not Canada, for one. But closer to that, Canada’s proximity to the United States (US) is concerning. As Dr Buchman rightly points out, the US has long required at least 3 years of training in an Accreditation Council for Graduate Medical Education–accredited program to qualify for board certification. At present, family physicians seeking to head south need to jump several hoops to qualify for board certification, which include either doing another year of residency in the US (or a deemed equivalent, such as an enhanced skills year), or being non-certified but “involved in family medicine” and a resident in the US for 6 months (presumably without pay) before challenging the board examination.8

 

These requirements are in place, obviously, to protect the domestic US market of family physicians. However, as Obamacare survived the November election, we also know the US will be hard pressed to recruit a vast amount of primary care physicians to provide service to the nearly 40 million Americans who will now have health insurance.9 We would, essentially, be making it easier for Canadian physicians to show equivalence of training and head south, particularly before the 4-year requirement is put in place.

 

Finally, Dr Buchman’s message also does not address the negative aspects that are associated with adding an extra year of residency training. Canadian physicians today are graduating with some of the highest debt levels ever seen.10 An additional year of resident-level pay pushes these residents toward greater delay of financial independence, which delays related issues such as starting a family, settling in a practice, and so on. Further, one can’t help but wonder if the addition of a third year of residency would be resented as a move to squeeze an additional “service” year out of a resident who is functioning at the level of a family physician.

 

We also know many medical students choose family medicine because of the length of training.11 How will we reverse the shortage of family physicians if family medicine training is 5 years long (like in Australia, which remunerates residents and registrars at rates far higher than those in Canada12) and does not have the remuneration parity or respect that other specialists derive from the same length of training? Finally, there is nothing to say that a third year would actually develop the skills that are in demand. At present, there are enhanced skills programs that those interested in further training can pursue. Is there something wrong with this system?

 

There are, to be sure, positives and negatives to be gained by moving to 3 years’ worth of family medicine residency. After an overwhelming endorsement from the President of the College of Family Physicians of Canada, I hope this letter highlights some of the potential pitfalls. As the old saying goes, “if it ain’t broke, don’t fix it.” The question of whether family medicine training as it stands today is “broke” should probably be debated first before we decide on a “fix.”

 

 

 

i had a strong feeling that Dr. Loh may be a pm101er... idk :S

[futureGP]

when they noted how hard it was to fill radiology and anaesthesia residencies, now that the internship was gone. I do not remember getting much support from the CCFP at that time.

 

WHTA?!?! 10char

[markov79]

forgive ignorance, but how did the internship differ from M3 or M4? or were they generally the same idea, with slightly different approaches to training somewhere (or something...)?

[futureGP]

forgive ignorance, but how did the internship differ from M3 or M4? or were they generally the same idea, with slightly different approaches to training somewhere (or something...)?

 

basically a new MD interning with some pay to explore areas in medicine + at the end of the year you can start practising medicine.

 

relieves pressure to choose a specialty early in the career, easier re-entry to specialty

[Real Beef]

That letter endorsing a 3rd year for family medicine is absolutely frightening! How easy it is for doctors who are far from their training days to endorse more and more time before you can actually practice and start making a living. Most of medicine I suspect is learned by trial of fire ... by actually practicing, making mistakes, learning on the spot not by having longer and longer periods of having a safety net. Having shadowed some family docs 3 years out from finishing their 2 year residency they still admit to not knowing everything .... does that mean that they should make it 5 years? of course not ... If they made family med 3 years by the time I reach Carms I will for sure just go for a specialty and say screw family med because for me the length of training is a consideration ... at three years it is not worth it might as well spend the extra two for something else then.

 

Beef

[Real Beef]

That is an amazing summary, Beef. I understand that this is an anonymous forum, but if you were to write a more-polished version of that and send it to the CFP journal or the CMAJ, it might turn some heads.

 

You're spot on though. Academic family med just doesn't get it.

 

An interesting idea. I drafted up a letter while procrastinating my studying but need a couple of extra references from Medical Education journals that I have read in the past ... i.e. older medical school entrance age predicts selection of FM. I will drop into the library for a librarian to help me with a reference search actually I know that the research dept at NOSM did this study so I might drop into their office on Monday. This is an interesting diversion if nothing else. Thanks for the suggestion.

 

Ill PM you a draft once I write it up and perhaps you can make a few editing suggestions.

 

Beef

[futureGP]

That letter endorsing a 3rd year for family medicine is absolutely frightening! How easy it is for doctors who are far from their training days to endorse more and more time before you can actually practice and start making a living. Most of medicine I suspect is learned by trial of fire ... by actually practicing, making mistakes, learning on the spot not by having longer and longer periods of having a safety net. Having shadowed some family docs 3 years out from finishing their 2 year residency they still admit to not knowing everything .... does that mean that they should make it 5 years? of course not ... If they made family med 3 years by the time I reach Carms I will for sure just go for a specialty and say screw family med because for me the length of training is a consideration ... at three years it is not worth it might as well spend the extra two for something else then.

 

Beef

 

this,

 

if family becomes a 3-year residency, you will definitely see a more significant drop in people going for family.

[Real Beef]

That is an amazing summary, Beef. I understand that this is an anonymous forum, but if you were to write a more-polished version of that and send it to the CFP journal or the CMAJ, it might turn some heads.

 

You're spot on though. Academic family med just doesn't get it.

 

So lets see if they publish my letter ....? I put a more polished version of my rant together with a handful of references. We'll see what the feedback is to my draft. I wasnt quite sure what to use as a 'title' to my letter as it really was just a letter ... oh well.

 

Beef

 

 

------------------------------

 

Dear Mr. XXXX

 

Your manuscript entitled "Older medical students concerned" has been successfully submitted online and is presently being given full consideration for publication in Canadian Family Physician.

 

Your manuscript ID is 2012-12-CFP-XXXXX.

 

Please mention the above manuscript ID in all future correspondence or when calling the office for questions. If there are any changes in your street address or e-mail address, please log in to Manuscript Central at http://mc.manuscriptcentral.com/cfp and edit your user information as appropriate.

 

You can also view the status of your manuscript at any time by checking your Author Center after logging in to http://mc.manuscriptcentral.com/cfp .

 

Thank you for submitting your manuscript to Canadian Family Physician.

 

Sincerely,

Mairi Abbott

Canadian Family Physician Editorial Office

ma@cfpc.ca

##

[AtomSmasher19]

It's funny how the CCFP thinks that length training correlates with prestige. When I found out a few years ago that becoming a GP required 2 years of residency instead of one, the prestige of GPs in my eyes was not changed at all.

 

Prestige is determined by the nature of the work, not length of training. If the public thinks specialists are more prestigous than GPs, it's because they perceive GPs as jacks of all trades, and specialists as experts.

 

Is there actually any evidence that the masses actually do have less respect for GPs? I doubt most people even know the difference between different kinds of doctors.

 

If more training makes someone MORE likely to choose that specialty, **** it, let's make FM into a 25 year residency, and see how many people sign up for it. According to CCFP logic, if this happened the GP shortage would disappear overnight.

[AtomSmasher19]

So lets see if they publish my letter ....? I put a more polished version of my rant together with a handful of references. We'll see what the feedback is to my draft. I wasnt quite sure what to use as a 'title' to my letter as it really was just a letter ... oh well.

 

Beef

 

 

------------------------------

 

Dear Mr. XXXX

 

Your manuscript entitled "Older medical students concerned" has been successfully submitted online and is presently being given full consideration for publication in Canadian Family Physician.

 

Your manuscript ID is 2012-12-CFP-XXXXX.

 

Please mention the above manuscript ID in all future correspondence or when calling the office for questions. If there are any changes in your street address or e-mail address, please log in to Manuscript Central at http://mc.manuscriptcentral.com/cfp and edit your user information as appropriate.

 

You can also view the status of your manuscript at any time by checking your Author Center after logging in to http://mc.manuscriptcentral.com/cfp .

 

Thank you for submitting your manuscript to Canadian Family Physician.

 

Sincerely,

Mairi Abbott

Canadian Family Physician Editorial Office

ma@cfpc.ca

##

 

Beef, I appreciate the initiative, but don't make yourself a martyr over this. Choose your words carefully if you choose to engage in this sort of activism at all. But if you're aiming for FM I guess it doesn't really matter anyway since there's no competition for those spots.

[TimmyMax]

Wow, I know both physicians whose letters the OP quoted at the beginning of this thread- one is an anesthesiologist with whom I have trained and worked with in Sudbury and the other is my best friend from medical school at UWO. Both are obviously quite outspoken on this issue and make great arguments.

[Real Beef]

AtomSmasher: Yeah I am not too concerned about martyrdom. Just figured they needed a med student's perspective ... I didnt say anything inflammatory just let them know that if they raise FM to 3 years I dont think many of my peers and I want to "play", will just go to another playground.

 

Beef

[AdamP]

you don't have to have that polished of a letter to get in cmaj. they like to publish med student opinion.

 

as for the first letter that was posted i think there has been a big change even from 2005-->2013 wrt the number of medical students choosing family medicine, obviously job prospects and better remuneration is helping with this, if you don't consider FM a lifestyle specialty then I'm not sure what is. now some people just could never stand being a fam doc and that's a different story.

 

but yeah things are different now than 2005, that being said, being in 3rd year staring down picking a career for the rest of my life the rotating internship sounds mighty sweet.

[rmorelan]

you don't have to have that polished of a letter to get in cmaj. they like to publish med student opinion.

 

as for the first letter that was posted i think there has been a big change even from 2005-->2013 wrt the number of medical students choosing family medicine, obviously job prospects and better remuneration is helping with this, if you don't consider FM a lifestyle specialty then I'm not sure what is. now some people just could never stand being a fam doc and that's a different story.

 

but yeah things are different now than 2005, that being said, being in 3rd year staring down picking a career for the rest of my life the rotating internship sounds mighty sweet.

 

As a fourth year last fall staring at CARMS apps it looked pretty sweet as well

[AtomSmasher19]

FPs are only going to gain more respect when their non-residency isn't seen as a backup plan, NOT through more years of training. That's only going to happen when FPs stop being paid so little for what they do, which I guess means never.

[1fuzzy2dino3]

you don't have to have that polished of a letter to get in cmaj. they like to publish med student opinion.

 

as for the first letter that was posted i think there has been a big change even from 2005-->2013 wrt the number of medical students choosing family medicine, obviously job prospects and better remuneration is helping with this, if you don't consider FM a lifestyle specialty then I'm not sure what is. now some people just could never stand being a fam doc and that's a different story.

 

but yeah things are different now than 2005, that being said, being in 3rd year staring down picking a career for the rest of my life the rotating internship sounds mighty sweet.

 

This is something i wholeheartedly agree with. given the structure of my program, we get a mere 12 weeks of elective time, and there is no way a 2 week stint in anesthesia, and then moving onto another 2 week stint in radiology - is going to give me enough wherewithall to make a career decision.

 

I've heard stories of people saying that rather than enjoy the bread and butter of surgery, they more-so liked their team. Imagine if I chose surgery b/c my team influenced my decisions, then in my PGY1 year I got a bad team with poor dynamics, AND then were to discover that I don't particulary enjoy the bread and butter of surgery. What then? utter devastation....

 

med ed needs to be revamped.

[Moderate]

If they made family med 3 years by the time I reach Carms I will for sure just go for a specialty and say screw family med because for me the length of training is a consideration ... at three years it is not worth it might as well spend the extra two for something else then.

 

Beef

 

Interesting.

 

So are you saying that a lot of people don't go into FM because they are interested in it but because it's the shortest residency?

 

Seems like a bad idea to pick a profession you don't like just to be done 3 years faster. you might be hating your job for the rest of your career just to save a couple of years of training?

[rogerroger]

Interesting.

 

So are you saying that a lot of people don't go into FM because they are interested in it but because it's the shortest residency?

 

Seems like a bad idea to pick a profession you don't like just to be done 3 years faster. you might be hating your job for the rest of your career just to save a couple of years of training?

 

 

I think non-med students and pre-clerks would be surprised how clerkship changes one's perspective on this. As someone who is in a five year program it was certainly tempting during CaRMS to consider just getting the training done with in 2 yrs vs 5. I would not be shocked if a bunch of FM residents would list this as a "top 3 reason" for selecting family. I also don't think there is anything wrong with wanting to just finish up and get out into the real workplace.

[apache]

honestly, it would be my number one and only reason, and i'd have to do plus one in emerg or something to keep my sanity... then again, 250 k in 2 years sounds great when you're drowning in debt, and want to enjoy the fruits of your labor now... lol, good thing my interests will end up in the states (yay for less time), and have to be two of the slackest residencies in terms of hours... cause seriously, over 60 hours a week... exclusion variable

 

I think non-med students and pre-clerks would be surprised how clerkship changes one's perspective on this. As someone who is in a five year program it was certainly tempting during CaRMS to consider just getting the training done with in 2 yrs vs 5. I would not be shocked if a bunch of FM residents would list this as a "top 3 reason" for selecting family. I also don't think there is anything wrong with wanting to just finish up and get out into the real workplace.

[Moderate]

I think non-med students and pre-clerks would be surprised how clerkship changes one's perspective on this. As someone who is in a five year program it was certainly tempting during CaRMS to consider just getting the training done with in 2 yrs vs 5. I would not be shocked if a bunch of FM residents would list this as a "top 3 reason" for selecting family. I also don't think there is anything wrong with wanting to just finish up and get out into the real workplace.

 

Hmmm, good point.

 

So are you saying that clerkship is super stressful and makes you want to finish training ASAP? I hadn't considered that.

[jerkoutnow2]

theoretically speaking,

 

if you went into med school because you enjoy medicine, then FM would have to be the most optimal choice (because by definition, a general medical practice encompasses all parts of medicine which all med students would like)

 

That used to be the case until the 2-year residency came along and students were now forced to find their 'life-long career'. And with that came a lot of pressure and burden to figure out what's 'right' for them even before they learn/experience what being an MD is to begin with (wouldn't you agree that a lot of students prep for residency even before they embark on clerkship + finish their preclerkship studies?) -- esp. if it's a competitive residency

 

a rotating internship just let that pressure off and really allowed students to enjoy working as a 'medical doctor' before considering any type of specialization to become an 'ologist'.

[jerkoutnow2]

Dr. Buchman made another comment to his article on CFP

 

and a part of it says this

 

http://www.cfp.ca/letters

But as expressed in my message, can we afford to wait 5-10 years to find out while fewer and fewer FPs practise broad-scope care and neglect environments (such as small town and rural Canada) because they don't have the clinical courage to actually experience that they are competent in these settings? My fear is I'm right. My hope is I'm wrong."

 

Not to endorse an ad hominem, but I'm wondering if FM graduates actually 'avoid' going into broad-scope care and avoid going to small towns and rural Canada because they don't think they're competent.

 

Is that really the reason why they're not going to practise rural + broad-scope care?

[rogerroger]

Hmmm, good point.

 

So are you saying that clerkship is super stressful and makes you want to finish training ASAP? I hadn't considered that.

 

I'm going to speak bluntly here. I hope I do not offend...

 

Most if not all people going into medicine neglect to understand or simply can't understand just how rubbish the hours can be. However, even if you do consider this fact even fewer grasp the effect these endless work hours have on one's other interests and lifestyle. We all love medicine. But lots of us love other things too.

 

One of the biggest things you learn in clerkship is what lifestyle choices are available through the different specialties. This is huge. During clerkship you glimpse the life of a family doc for 2 months then that of a surgeon then that of an internist etc. You also start experiencing call... Call blows. Few jobs with the exception of certain military roles demand you stay awake and working 26-30 hrs straight. Do you know how much life sucks when you got a couple of these days a week? Do this 6-8 times a month and your month is consumed with work and sleep. Don't forget when you are not on call you still often pull 10-12hr work days. Sure, it gets a bit better after residency, but that is all relative to the lifestyle options avaiable to staff in other specalties. Due to these factors many quickly notice that they might love the field but they can't stand the scene (eg. lifestyle choice) that goes along with it.

 

By the end of clerkship people often divide themselves into one of two camps. You have the folks who are speciality focused versus those who are lifestyle focused.

 

Go look at the most competitive specialties, derm, optho, rads, emerg, anesthesia, plastics etc. Compared to most specialties these compensate well and even better when you consider the hours worked. But they also provide fairly good hours and work life balance. Family med has a lot of spots and therefore is less competitive. But family is also lifestyle focused. Also you can do a lot of specialized stuff as a family doc, palliative, emerg, pain med, sports med, the list is huge. You don't have to do general family. To a lot of people family starts looking pretty good when you consider the work enviroment I mentioned above.

 

I'm not in family med, but when selecting my specality choice lifestyle was a big factor. I love medicine. But I love other things just as much and medicine will only be part of what I do. With this mindset I appreciate why many gravitate towards FM.

[Nucklehead]

I was all gung-ho to specialize until I saw first hand the sh*t storm that residency is. Five years doesn't sound too bad before you're in the thick of it. When you're slapping yourself in the face to stay awake at 4 am Sunday morning while you write admission orders...second thoughts start creeping in.