Should Family Medicine be a 3 year residency?

[la marzocco]

10 minutes ago, GrouchoMarx said:

the problem is four year schools persist when there is evidence that three year schools produce doctors of the same competence. imo the fourth year of medical school is vestigial.

my model would be like this: every student would complete:

3 years of medical school

2 years of family medicine residency

royal college specialty residency if you want.

 

there. everyone gets to practice as a family doctor if they want. specialists will have gone through family and understand the perspective of family doctors. everyone has more mobility. specialists with poor job prospects could do family medicine in the meantime. i cant see any real downside.

sure some of the specialists will disagree with me saying that it adds on years to their training, but i would argue that it doesnt. the family residency would act as an internship in most cases. in some, such as surgery, well, who cares. its a sacrifice. and given the job market for things like ortho, maybe theyd be better off.

Quite like this idea. The whole point of med school is to produce the "undifferentiated" physician anyway. 

[rmorelan]

2 minutes ago, la marzocco said:

Quite like this idea. The whole point of med school is to produce the "undifferentiated" physician anyway. 

There are many people that would prefer that approach - the issue is that family doctors in particular took a lot of steps not to simply be a default option to increase their political position among other goals. That move lead to dramatically increased incomes for them and restored the value in many other important ways of the profession. 

Also if that year just replaced our first year of residency - in order words an internship year - it wouldn't add any time at all. 

[Snowmen]

To take care of the "added year" concern, simply make the first year of FM residencies uniformed across Canada as a rotating internship and have the specialty match after this standardised first year. GPs would start practicing a year earlier while it would change nothing for specialists but they would still get an additional year of clinical training.

[distressedpremed]

20 minutes ago, GrouchoMarx said:

the problem is four year schools persist when there is evidence that three year schools produce doctors of the same competence. imo the fourth year of medical school is vestigial.

my model would be like this: every student would complete:

3 years of medical school

2 years of family medicine residency

royal college specialty residency if you want.

 

there. everyone gets to practice as a family doctor if they want. specialists will have gone through family and understand the perspective of family doctors. everyone has more mobility. specialists with poor job prospects could do family medicine in the meantime. i cant see any real downside.

sure some of the specialists will disagree with me saying that it adds on years to their training, but i would argue that it doesnt. the family residency would act as an internship in most cases. in some, such as surgery, well, who cares. its a sacrifice. and given the job market for things like ortho, maybe theyd be better off.

I agree with this as well, but this is very similar again to the rotating internship where people were "GP's". 

Currently the CCFP does not agree with this system because it reduces their specialty to the lowest common denominator again. 

It will be very hard to go back again. Sadly not feasible due to political pressures...there have been other threads about this before. 

[rmorelan]

13 minutes ago, distressedpremed said:

I agree with this as well, but this is very similar again to the rotating internship where people were "GP's". 

Currently the CCFP does not agree with this system because it reduces their specialty to the lowest common denominator again. 

It will be very hard to go back again. Sadly not feasible due to political pressures...there have been other threads about this before. 

I agree going backwards will not be easily. 

Ha, the only way (and I really would doubt it) is if the no FM specialists cared enough to create a GP stream in their system (say just like FM can do emerg and licences for it, the Royal college would do the same in reverse for FM). Cannot see that happening, but I think it would still be more likely than FM going away. 

[Snowmen]

What about creating a three-tier system with:

1) GPs which have completed a single year and are basically FPs with a limited score of practice such as only walk-ins (perhaps like a more autonomous NP with a wider scope of practice?).

2) FPs which are allowed to complete R3 specializations, work in academic fields and do hospitalist work unlike GPs.

3) Specialists which would be exactly the same as they are now.

Moving to a 3-year or 6-year residency instead of 2 or 5 while maintaining the same total timeframe (by moving to 3-year medical schools) would also provide the added benefit of having more residents (50%/20% more for FPs/specialists) in the system which would mean better working conditions while maintaining the same exposure and total training time --> less call and less hours.

The 3rd or 6th year could be implemented as an unofficial fellowship/R3, allowing residents to work on fields they have a particular interest in or feel they need to improve. This would be a very good fit for the "transition to practice" concept in competency-based residency.

[FailureToThrive]

46 minutes ago, GrouchoMarx said:

the problem is four year schools persist when there is evidence that three year schools produce doctors of the same competence. imo the fourth year of medical school is vestigial.

my model would be like this: every student would complete:

3 years of medical school

2 years of family medicine residency

royal college specialty residency if you want.

 

there. everyone gets to practice as a family doctor if they want. specialists will have gone through family and understand the perspective of family doctors. everyone has more mobility. specialists with poor job prospects could do family medicine in the meantime. i cant see any real downside.

sure some of the specialists will disagree with me saying that it adds on years to their training, but i would argue that it doesnt. the family residency would act as an internship in most cases. in some, such as surgery, well, who cares. its a sacrifice. and given the job market for things like ortho, maybe theyd be better off.

This is genius, can you work for the government please?

[distressedpremed]

8 minutes ago, rmorelan said:

I agree going backwards will not be easily. 

Ha, the only way (and I really would doubt it) is if the no FM specialists cared enough to create a GP stream in their system (say just like FM can do emerg and licences for it, the Royal college would do the same in reverse for FM). Cannot see that happening, but I think it would still be more likely than FM going away. 

I agree that this is tough...I mean no one wants to be the lowest common denominator, I can see why they advocated for it.

However, they have to realize that the problem with this shift is that medical school has now essential been just a post that people have to pass during the race. It has become somewhat of a checkmark - you need to pass this to get into residency. But you have to match to residency to be a physician. I don't think the actual cost matches the value that it provides anymore - to our pockets and to the system. 

I agree that fourth year was largely me spending more money on top of tuition...then the actual clinical "rotations" had nothing to do with my specialty. at all. 

I remember an administrator rudely telling me "you'll make tons of money, don't complain about the interview/CaRMS cost". 

In the best quote from The Incredibles, "when everyone is super, no one is!" 

[indefatigable]

38 minutes ago, Snowmen said:

What about creating a three-tier system with:

1) GPs which have completed a single year and are basically FPs with a limited score of practice such as only walk-ins (perhaps like a more autonomous NP with a wider scope of practice?).

2) FPs which are allowed to complete R3 specializations, work in academic fields and do hospitalist work unlike GPs.

3) Specialists which would be exactly the same as they are now.

Moving to a 3-year or 6-year residency instead of 2 or 5 while maintaining the same total timeframe (by moving to 3-year medical schools) would also provide the added benefit of having more residents (50%/20% more for FPs/specialists) in the system which would mean better working conditions while maintaining the same exposure and total training time --> less call and less hours.

The 3rd or 6th year could be implemented as an unofficial fellowship/R3, allowing residents to work on fields they have a particular interest in or feel they need to improve. This would be a very good fit for the "transition to practice" concept in competency-based residency.

I'd guess as a downside there'd be a bit of turf war between 1) & 2) especially if there was a significant income differential.  And the line to me between 1) & 2) would be blurry in rural situations where there are service issues currently with FPs.  I mean to some extent it would solve the matching situation, but not address the service issue - urban centres have no issues with providers.  Would it decrease the quality of care available in rural centres?  Finally, hospitalist work is fairly popular so disallowing 1) GPs to do that type of work could mean an uncomfortable default option, supposing 2) would be competitive.   

[medigeek]

2 hours ago, Snowmen said:

To take care of the "added year" concern, simply make the first year of FM residencies uniformed across Canada as a rotating internship and have the specialty match after this standardised first year. GPs would start practicing a year earlier while it would change nothing for specialists but they would still get an additional year of clinical training.

Then you end up with even less knowledge and skills. It's an asset in Canada that family doctors can handle a bit more of the complex stuff and hence makes Canada is one of the best countries globally if you're a family doctor. But you need the time and training to know what you're doing....

[rmorelan]

20 minutes ago, medigeek said:

Then you end up with even less knowledge and skills. It's an asset in Canada that family doctors can handle a bit more of the complex stuff and hence makes Canada is one of the best countries globally if you're a family doctor. But you need the time and training to know what you're doing....

any new configuration - if such a thing were ever to happen - definitely would have to treat the 2 years as if it was a family medicine specialty. The old training approach wouldn't work. I would have no problem if med school was 3 years for all, 2 years of FM and then 4 years for a standard specialty but family medicine really is its own thing that needs it own time to develop. 

Now that would actually put a huge amount of pressure on family medicine training - as it would effectively double to triple the number of trainees. 

It also I think would be pushed against by many medical schools. Many four year programs for instance believe medicine should be 4 years - that is necessary to properly develop core skills as well. 

Another interesting idea would be to specifically allow family doctors to re-enter the CARMS system as first round applicants - of course in this restricted CARMS spots world we are in now that sounds painful ha, but it is cheaper than having everyone do family medicine and still allows that those that were forced into in a sense opportunities to leave it just like GPs had before. 

[ralk]

2 hours ago, GrouchoMarx said:

the problem is four year schools persist when there is evidence that three year schools produce doctors of the same competence. imo the fourth year of medical school is vestigial.

my model would be like this: every student would complete:

3 years of medical school

2 years of family medicine residency

royal college specialty residency if you want.

 

there. everyone gets to practice as a family doctor if they want. specialists will have gone through family and understand the perspective of family doctors. everyone has more mobility. specialists with poor job prospects could do family medicine in the meantime. i cant see any real downside.

sure some of the specialists will disagree with me saying that it adds on years to their training, but i would argue that it doesnt. the family residency would act as an internship in most cases. in some, such as surgery, well, who cares. its a sacrifice. and given the job market for things like ortho, maybe theyd be better off.

I fully agree with reducing medical school for 3 years - there's so much that gets taught in med school that is absolutely worthless - but forcing everyone through a fully FM residency both eliminates any gains from that reduction in medical school training times and would be wildly impractical. We're already short on resources to run quality, useful FM residencies, there's no way there would be enough useful space in clinics to train that massive number of residents. And FM residency would be a very, very inefficient way to train future specialists - heck, it's not even optimized to train the average FP! Too much of the knowledge and skills developed in FM residency have little value in most specialties. And few specialties' intern years come anywhere near resembling what FM residencies look like these days - beyond the block of CTU and block of ER that literally every specialty does, there's little overlap. Specialties wouldn't be able to jump right to PGY-2 under your proposed system and be anywhere near where they would be under the current one.

I get the desire for all graduating CMGs to have some sort of back-up in case of a poor job market - typically with FM as the dumping ground for those who can't establish themselves in the specialties they actually want - but systems that flexible are also incredibly inefficient (during a time when both healthcare and medical education dollars are tight). We're seeing increasing specialization for good reason, because it's safer for patients and keeps training times for learners from spiraling even further out of control during a time when the breadth of medical knowledge is expanding exponentially and changing quickly. Two years of FM training would be near-useless if you stick 5+ years of specialty training between it and actual practice - beyond what would be a significant loss of knowledge and skills during that intervening time, practice changes fast enough that a person who hasn't done FM in 5 years is going to be significantly out of date with respect to current standards of care. At some point, for patients' safety more than anything else, learners need to pick a lane and either stick with it, or switch to another path by starting back at the beginning.

I think it's also important to note that most CMGs who want to practice FM still can under our current system - specialists transferring into FM are common and most unmatched students can end up in FM if they want to (and apply sufficiently broadly). There are some holes in this system which can and should be addressed, and I've been advocating for the MD degree itself to have some intrinsic value beyond landing a residency (such as working in a role similar to a PA or NP). Yet, the current system has more flexibility than we give it credit for once you dig into the gritty details. If we made FM positions even just a little more accessible to CMGs who aren't in their graduating year, then we could have the same timeline you've recommended but without a requirement that everyone go through it. 3 year MD program --> 5 year specialty training --> 2 year FM training if the specialist route doesn't work out. Exact same training times as doing the FM training right after medical school, but only those who need/want it have to go through it, and that knowledge leads right into practice rather than coming half a decade away from it.

[NLengr]

On 23/02/2018 at 1:11 PM, rmorelan said:

There are many people that would prefer that approach - the issue is that family doctors in particular took a lot of steps not to simply be a default option to increase their political position among other goals. That move lead to dramatically increased incomes for them and restored the value in many other important ways of the profession. 

Also if that year just replaced our first year of residency - in order words an internship year - it wouldn't add any time at all. 

The issue I see about replacing the first year with a rotating internship, at least in my experience, is that in my residency that would end up adding an extra year unless the RC does a major revamp of the way the programs in my specialty need to be structured. The first year is basically all surgical experience and is required (except for a few electives). 

It could be done I suppose but the RC would have to revamp a ton of requirements. 

[rmorelan]

1 hour ago, NLengr said:

The issue I see about replacing the first year with a rotating internship, at least in my experience, is that in my residency that would end up adding an extra year unless the RC does a major revamp of the way the programs in my specialty need to be structured. The first year is basically all surgical experience and is required (except for a few electives). 

It could be done I suppose but the RC would have to revamp a ton of requirements. 

not that they will but with competency education they have that one time when they already are revising things. 

[A-Stark]

23 hours ago, NLengr said:

The issue I see about replacing the first year with a rotating internship, at least in my experience, is that in my residency that would end up adding an extra year unless the RC does a major revamp of the way the programs in my specialty need to be structured. The first year is basically all surgical experience and is required (except for a few electives). 

It could be done I suppose but the RC would have to revamp a ton of requirements. 

I think in the Old Days there were internships with varying focus, e.g. mainly medicine or mainly surgery or more of a mix. 

[Dikolator]

On 2/23/2018 at 0:04 PM, Snowmen said:

What about creating a three-tier system with:

1) GPs which have completed a single year and are basically FPs with a limited score of practice such as only walk-ins (perhaps like a more autonomous NP with a wider scope of practice?).

2) FPs which are allowed to complete R3 specializations, work in academic fields and do hospitalist work unlike GPs.

3) Specialists which would be exactly the same as they are now.

Moving to a 3-year or 6-year residency instead of 2 or 5 while maintaining the same total timeframe (by moving to 3-year medical schools) would also provide the added benefit of having more residents (50%/20% more for FPs/specialists) in the system which would mean better working conditions while maintaining the same exposure and total training time --> less call and less hours.

The 3rd or 6th year could be implemented as an unofficial fellowship/R3, allowing residents to work on fields they have a particular interest in or feel they need to improve. This would be a very good fit for the "transition to practice" concept in competency-based residency.

None of the existing players benefit from this, aside from medical students that let's be honest, don't have any political advocacy.

FRCPC/SC programs maintains their enrollment numbers despite dismal career prospects because they require bodies to staff tertiary/teaching centres. They are NOT going to be happy about losing 1 year of service times however-many PGYs they take in. They may compensate by taking in MORE, which exacerbates the problem for graduates.

CFPC does not benefit from this from any angle. This is an erosion to their foundation no matter how you slice it.

Does learning improve? I'd hate to be stuck doing clinical rotations for 1 year which does not contribute to my career goal in any way. Imaging how that would impact group based learning, which most of the schools are transitioning towards.

Does patient care improve? You will end up with more disgruntled "gunners" in specialties stuck doing family medicine, either still trying to pad their app for positions or those who are disillusions or feel disenfranchised by the whole system.

Honestly the best way I can think of is getting rid of CaRMS altogether. Make it an application based system with need-based quotas in each health care system/LHIN.

[JohnGrisham]

"Honestly the best way I can think of is getting rid of CaRMS altogether. Make it an application based system with need-based quotas in each health care system/LHIN."

Not sure how that solves anything.  CaRMS is working quite well.  There just needs to be a bit more funding for positions, or decreased enrollement in medical school.  Scrapping an very effective system would be foolish. There is absolutely nothing wrong with CaRMS itself, the algorithm etc.  Sure some minor things related to the process, but overall it is quite good.   It is the input of lack of positions for the demand that is the issue.

[DermJuly2018PGY1]

15 minutes ago, JohnGrisham said:

Decreased enrollment in medical school. 

This x 1000. No sense having more funding for positions when the job market is then saturated. Decrease medical school enrollment, and problem solved. But schools/universities don't want that, they get more $$$ with more students.

[Dikolator]

23 hours ago, JohnGrisham said:

"Honestly the best way I can think of is getting rid of CaRMS altogether. Make it an application based system with need-based quotas in each health care system/LHIN."

Not sure how that solves anything.  CaRMS is working quite well.  There just needs to be a bit more funding for positions, or decreased enrollement in medical school.  Scrapping an very effective system would be foolish. There is absolutely nothing wrong with CaRMS itself, the algorithm etc.  Sure some minor things related to the process, but overall it is quite good.   It is the input of lack of positions for the demand that is the issue.

If you don't think there's a mismatch between residency spots and job prospects in many specialties, then I guess CaRMS is good enough. Talk to the fellows at your institution and see what they say.

[JohnGrisham]

1 hour ago, Dikolator said:

If you don't think there's a mismatch between residency spots and job prospects in many specialties, then I guess CaRMS is good enough. Talk to the fellows at your institution and see what they say.

That is a funding issue outside of the CaRMS process itself.  People should be advocating for more funding in those specialties then, or yes, shifting positions from residencies with less job prospects(due to lack of funding) to those with better prospects(primary care).

My point was the actual algorithm and centralized nature of CaRMs itself is not an issue. It is the lack of funding downstream and poor planning.  

That is not to say there isn't a NEED for those specialties. Need =/= job prospects. That is purely a funding thing. We have a need for surgeons and surgeries, but just not the proper funding to allow them to work and fulfill the available demands. 

The system we have in place, in many many many ways tries to limit and ration healthcare spending dollars.  There is WAY more demand available for healthcare services than we are currently providing. A good way to limit the provision of care is by simply limiting the # of providers able to provide that care. For the hospital based specialties, its a bit easier to do this, than say a GP who once licensed can work as little or as much as they want (on their own dime of course with respect to operating expenses).

[ralk]

1 hour ago, Dikolator said:

If you don't think there's a mismatch between residency spots and job prospects in many specialties, then I guess CaRMS is good enough. Talk to the fellows at your institution and see what they say.

This is just a gross misunderstanding of what CaRMS actually does. CaRMS has no control over the number, location, or composition of residency spots. That's decided by a combination of governments (primarily provincial governments), schools, and programs themselves. You could scrap CaRMS entirely and it wouldn't make any difference to the mismatch between residency spots and job prospects.

[Edict]

So glad that this started such an informative discussion. I actually learned a lot from the family medicine residents/physicians here, before I was in favour of 3 year residency but now I can see the reasons for a 2 year family medicine residency. 

 

 

[Dikolator]

4 hours ago, JohnGrisham said:

That is a funding issue outside of the CaRMS process itself.  People should be advocating for more funding in those specialties then, or yes, shifting positions from residencies with less job prospects(due to lack of funding) to those with better prospects(primary care).

My point was the actual algorithm and centralized nature of CaRMs itself is not an issue. It is the lack of funding downstream and poor planning.  

That is not to say there isn't a NEED for those specialties. Need =/= job prospects. That is purely a funding thing. We have a need for surgeons and surgeries, but just not the proper funding to allow them to work and fulfill the available demands. 

The system we have in place, in many many many ways tries to limit and ration healthcare spending dollars.  There is WAY more demand available for healthcare services than we are currently providing. A good way to limit the provision of care is by simply limiting the # of providers able to provide that care. For the hospital based specialties, its a bit easier to do this, than say a GP who once licensed can work as little or as much as they want (on their own dime of course with respect to operating expenses).

I apologize for mislabelling CaRMS something more encompassing than the Nobel-prize winning algorithm itself.

I do agree people should advocate for a correction in the misallocation of postgraduate training funding. I have very little faith this can be achieved through advocacy alone. Many political interests are in play.

[medigeek]

On 3/18/2018 at 1:26 PM, JohnGrisham said:

That is a funding issue outside of the CaRMS process itself.  People should be advocating for more funding in those specialties then, or yes, shifting positions from residencies with less job prospects(due to lack of funding) to those with better prospects(primary care).

My point was the actual algorithm and centralized nature of CaRMs itself is not an issue. It is the lack of funding downstream and poor planning.  

That is not to say there isn't a NEED for those specialties. Need =/= job prospects. That is purely a funding thing. We have a need for surgeons and surgeries, but just not the proper funding to allow them to work and fulfill the available demands. 

The system we have in place, in many many many ways tries to limit and ration healthcare spending dollars.  There is WAY more demand available for healthcare services than we are currently providing. A good way to limit the provision of care is by simply limiting the # of providers able to provide that care. For the hospital based specialties, its a bit easier to do this, than say a GP who once licensed can work as little or as much as they want (on their own dime of course with respect to operating expenses).

Cutting government waste and pushing those funds to create more physician jobs to meet the wait times/demand would be the smart thing. Also trim off med school enrollment a bit. 

[NeuroD]

On 3/17/2018 at 1:12 PM, DermJuly2018PGY1 said:

This x 1000. No sense having more funding for positions when the job market is then saturated. Decrease medical school enrollment, and problem solved. But schools/universities don't want that, they get more $$$ with more students.

Unless you want to control a profession that historically had a lot of power by artificially tipping supply and demand in your favor. People seem to keep missing this. I can't help but think that's a big part of it.