how do people get through FRCPC residences?

[offmychestplease]

I say this as someone who wants FM so please help me see this from the other perspective.

Major props but I genuinely can't understand it. How does one get through 5-6 year FRCPC residences followed by 1-2 year fellowships on average for most fields? That is 6-8 years of brutal work after medical school (compared to 2 for FM)? For many of us it was a brutal grind getting into medical school...followed by medical school itself, and then grinding for another 6-8 years after medical school. The reason I am making this thread is because I find some people early on in medical school not phased by the commitment needed for any speciality besides FM. People are so quick to talk about/dream about/gun for any FRCPC field they find cool/interesting without giving second thought to the time commitment needed. And as far as I know...it's not "just 6-8 years" but a brutal 6-8 year grind in residency and fellowship. In Canada, the average age of starting residency is 28 which means on average you would be attending at 34-36 after finishing FRCPC residency and fellowship. 

Has anyone started medical school starry eyed for FRCPC fields but as medical school went on FM became more and more attractive as they realized that they had enough of the grind? I heard that sometimes even senior medical students just aren't aware of the grind and actually switch into FM during year 1/2 of their FRCPC fields. 

[robclem21]

I think this a very personal decision and the rationale for pursuing a particular specialty is unique to each individual. There is no doubt that what you have said is accurate with regards to residency and fellowship training being a grind. Medical students should always consider the downside to any speciality training in addition to what they love and make an informed choice. That being said, training time is only one factor to consider and the fact of the matter is, it often is not enough of a deterrent to stop someone from pursuing a career they love. At the end of the day, 3-4 years of extra training to have a career you can truly be happy in for 20-40 years of practice is worth it for most people, and it doesn't particularly make sense to me to grind into and through medical school only to opt for a shorter training time in the home stretch and not be happy in your career. There are definitely people who switch into family medicine once they realize their FRCPC specialty is not for them. However, I have also seen many take the opposite path, switching from family med once they realize and develop new interests. Everyone is different.

Sadly, despite 4-8 weeks rotating in each specialty during clerkship, for many it is tough to get a true depiction of what practice is like, and most of us make an educated guess as to what we are interested in doing. It isn't uncommon for some people to have second thoughts and switch specialties. This is why it's important to really give every specialty a chance when you enter medical school and take a lot of time to explore different options.

In regards the question in the title of your thread, its a combination of constant elevated blood caffeine concentrations, close friendships with colleagues/co-residents to vent/complain, spending as much time with friends and family as possible, but mostly just lots of burnout and grinding through. You have to build resiliency skills in your life before you start residency or else it's gonna be a tough ride.

[ellorie]

The problem is, in order to do FM, you have to have the talent and liking for FM - I feel like it's a mistake to think of FM as a default option.  The skill set of FM I think is one that I would not be well suited for at all - I can't change tasks or mindsets very fast, I get really stressed out by the unknown, don't like ambiguity, the whole "a little about a lot" thing is very ill suited to my strengths and general personality.

Plus for some things, like psych, you really can be out and done in 5 years - 3 more years isn't so many if you get to do something you're good at at the end of it.  Plus psych residency is overall pretty tolerable.

That said, I emerged from residency super burned out and am still super burned out so -shrug-

[shikimate]

Many people in 1st/2nd year dream of a field only to switch to FM later on, it's relatively common. Actually some of the highest achievers in our class ended up in FM. 

If you talk to residents, I bet there are a good number in their R3/R4 who wish they would've just did FM and be over with. That's why people were upset royal college wanted to make internal medicine 5 years, because a lot of IM residents just wanted out after 4 years and do GIM.

With competency based models it's possible to finish earlier. Ottawa anesthesiology pilot cohort was only 4 years instead of 5.

Our model of residency is not very well structured compared to other countries, that might explain why people struggle so much making decisions as to what they want to do:

- in USA, a lot of residencies are shorter, and there are greater opportunities to transfer between different specialties. In Canada it's a pain to switch from one residency to another. 

- in UK/other commonwealth countries, you have greater freedom to do internship/house officer work before committing to a field. It used to be like this in Canada until they got rid of the general license after 1 year of internship. Now students are stuck gunning for something in MS1 lol.

- we got rid of a general license, whereas other countries including USA still give out licenses to people who have some post-grad training, but perhaps decide not to complete their full residency and write certification. In Canada, unless you're certified, you're nobody, so basically that forces you to finish a residency you started (and study for the exam). I think that is a waste of resources. Someone who completed 3-4 years of a 5-6 year residency might not be able to do the most complex cases, but they certainly have a good set of skills to do the basic stuff in that field. There are residents out there who actually quit their residency and decide to do other stuff in life. 

[Hanmari]

As someone late into an RC residency, I do think looking back at it from a purely financial/YOLO perspective it would've made more sense to do FM given that the 3 extra years is actually more like a decade of setback for finances/life outside of medicine. That being said, as multiple posters above have said I also feel I could not have tolerated the day to day work of office FM. Even if you're planning to RE asap, you'd probably end up working at least 10 years in the field and that's a long time to be unhappy with your work - it's certainly longer than residency. The extra grind becomes more bearable in that context. I did omit looking into the FM niches, but since I did not have the motivation to look beyond the standard med school curriculum, I've made my peace with that.

[1D7]

IMO FM should be the default choice for medical students. Obviously if one dislikes it they should not do it.

For 5+ year residencies/specialties you have to deal with...

• Doing 24 hr call or night float which grinds most residents down after 5+ years (even if you have chill rotations in between brutal ones). FM not only does 3 fewer years of the grind, but in many cases doing FM means you will no longer regularly have overnight work postresidency. Most surgeons, interventionalists (cards/IR), radiologists, and anesthesiologists will take call (yes there are ways to get around it in each specialty but those are the minority). The 5 year ER docs are also stuck doing shift work for life, whereas doing FM means you can find a way to return to a 9-5 kind of job.
• Further loss of personal life autonomy/independence. Not only are you stuck at one place for a few years longer, if you do a fellowship there's a good chance you have to move around and disrupt your life all over again. Job opportunities are usually more limited in specialties as compared to FM so you're more likely to relocate for your job as well.
• Studying for one big exam at the end of the 5 years. Most people do not have the willpower to do the majority of their studying early on (while taking on call and doing research) so this just means more material to stress over.
• Greater malpractice risk (mostly for surgeons and interventionalists)
• Additional income from some 5+ year residencies isn't much given the opportunity cost of 700k-1.2 mill+ in earnings, as well as compounding debt (or lack of investments).
  • On top of that in specialties with tight job markets you may have to work in conditions where someone else (corporation/senior physician partners) extract a certain % from your billings. This happens most in desirable & saturated locales. So while the new grad specialist is billing a good amount more than a FM, the actual take-home difference is much less than what billings show.
  • You may be underemployed (e.g. lack OR time in a surgical heavy field or any field primarily working with limited hospital resources). Again this is worst for new graduates.
  • Some specialists (mostly paediatrics) just straight up gross less for more years of training.
• Typically worse employment location flexibility even for established specialists
• Residency flexibility for family planning can be more difficult in certain fields

Seriously the only specialties where you're mostly living a normal-ish life for most of residency are dermatology, maybe radonc, lab specialties, and nuclear medicine (and the latter 3 have issues with employment).

I am not saying FM is perfect or that FM training is a piece of cake, but I think medical students need to hear these sort of things because they are usually shielded from the struggles of residents and new graduates in specialist fields.

[1D7]

As for OP's post, I think mainly you should avoid FM if you dislike it (which is not uncommon to be fair), or have an absolute need for a different kind of workflow/specialized patient population (understanding that there is a certain sacrifice to obtain that).

The most common bad reason I see students avoiding FM are because they invested very early into an identity that is incongruent with it (i.e. I "have" to be a surgeon, a woman's health specialist, mental health specialist, etc.). Although there are exceptions, if you go into a specialty dismissing it, you will probably come out thinking that way too. "Prestige" is another pretty bad one, though I think this is less common now.

[offmychestplease]

59 minutes ago, 1D7 said:

IMO FM should be the default choice for medical students. Obviously if one dislikes it they should not do it.

For 5+ year residencies/specialties you have to deal with...

• Doing 24 hr call or night float which grinds most residents down after 5+ years (even if you have chill rotations in between brutal ones). FM not only does 3 fewer years of the grind, but in many cases doing FM means you will no longer regularly have overnight work postresidency. Most surgeons, interventionalists (cards/IR), radiologists, and anesthesiologists will take call (yes there are ways to get around it in each specialty but those are the minority). The 5 year ER docs are also stuck doing shift work for life, whereas doing FM means you can find a way to return to a 9-5 kind of job.
• Further loss of personal life autonomy/independence. Not only are you stuck at one place for a few years longer, if you do a fellowship there's a good chance you have to move around and disrupt your life all over again. Job opportunities are usually more limited in specialties as compared to FM so you're more likely to relocate for your job as well.
• Studying for one big exam at the end of the 5 years. Most people do not have the willpower to do the majority of their studying early on (while taking on call and doing research) so this just means more material to stress over.
• Greater malpractice risk (mostly for surgeons and interventionalists)
• Additional income from some 5+ year residencies isn't much given the opportunity cost of 700k-1.2 mill+ in income, as well as compounding debt (or lack of investments).
  • On top of that in specialties with tight job markets you may have to work in conditions where someone else (corporation/senior physician partners) extract a certain % of your billings. This happens most in desirable & saturated locales. So while the new grad specialist is billing a good amount more than a FM, the actual take-home difference is much less than what billings show.
  • You may be underemployed (e.g. lack OR time in a surgical heavy field or any field primarily working with limited hospital resources). Again this is worst for new graduates.
  • Some specialists (mostly paediatrics) just straight up gross less for more years of training.
• Typically worse employment location flexibility even for established specialists
• Residency flexibility for family planning can be more difficult in certain fields

Seriously the only specialties where you're mostly living a normal-ish life for most of residency are dermatology, maybe radonc, lab specialties, and nuclear medicine (and the latter 3 have issues with employment).

I am not saying FM is perfect or that FM training is a piece of cake, but I think medical students need to hear these sort of things because they are usually shielded from the struggles of residents and new graduates in specialist fields.

Thank you for this post. I was aware of most of this myself due to years of research + asking around. This solidified FM for me. One of the most interesting points that I learned was that FM can bill more than many specialists if they are in the correct practice setting and work hard...years earlier as well. In fact, FM is routinely the most common field found in those province's top biller lists after optho/rads/cards. This is in response to the misguided assertion that some people don't want FM due to monetary reasons. And even if office FM was not your cup of tea...there are so many niches/+1's/practice types you can carve out for yourself. If your life dream is to operate on someone's brain (and don't mind everything that goes with that)...I completely get it - FM is not for you but how many people is that?

So I wonder tho- how common knowledge are the points that you made? I suspect if every medical student was aware of them unless you had a very burning passion for a field other than FM, FM really is a no-brainer on all accounts (income opportunity, jobs, lifestyle, variety, etc). It seems to me that schools don't present these points often when it comes down to talking about FM VS FRCPC the training time is literally the only thing ever compared.

[1D7]

9 minutes ago, offmychestplease said:

Thank you for this post. I was aware of most of this myself due to years of research + asking around. This solidified FM for me. What adds more salt on the wounds is that FM can bill more than many specialists if they are in the correct practice setting and work hard...years earlier as well. This is in response to the misguided assertion that some people don't want FM due to monetary reasons. I wonder tho- how common knowledge are the points that you made? I suspect if every medical student was aware of them unless you had a very burning passion for a field other than FM, FM really is a no-brainer on all accounts (income opportunity, jobs, lifestyle, variety, etc). 

I might be naive but I think most modern medical students do not really consider income as a high factor in their decision making. I really think most pediatricians wanted to work with kids, orthopods with bones, radiologists with scans, or at least they did when they were medical students deciding on the specialty. After personal interest I think most students would rate lifestyle as the next most important.

And priorities also change with age. After one has a family, being a resident taking frequent overnight call becomes exponentially more difficult (not that it is easy to run a FM clinic either but there is more flexibility as staff than as a resident). Being a badass trauma surgeon is a bit less appealing when it comes at cost of spending time with your kid. Usually this shift happens after medical school though. In general I think a lot of the issues with being a resident I mentioned are hard to grasp until you've spent a few years living it.

[W0lfgang]

If you want subspecialty, give up on the idea of work-life balance and accept that it's a 6 to 8 year beat-down. This is the price you pay to be among the best in the world. If it's easy, everyone would do it. I'm glad it's tough, and it wasn't even that bad. The payoff at the end, in my opinion, is well worth it.

[Snowmen]

1 hour ago, offmychestplease said:

Thank you for this post. I was aware of most of this myself due to years of research + asking around. This solidified FM for me. One of the most interesting points that I learned was that FM can bill more than many specialists if they are in the correct practice setting and work hard...years earlier as well. In fact, FM is routinely the most common field found in those province's top biller lists after optho/rads/cards. This is in response to the misguided assertion that some people don't want FM due to monetary reasons. And even if office FM was not your cup of tea...there are so many niches/+1's/practice types you can carve out for yourself. If your life dream is to operate on someone's brain (and don't mind everything that goes with that)...I completely get it - FM is not for you but how many people is that?

So I wonder tho- how common knowledge are the points that you made? I suspect if every medical student was aware of them unless you had a very burning passion for a field other than FM, FM really is a no-brainer on all accounts (income opportunity, jobs, lifestyle, variety, etc). It seems to me that schools don't present these points often when it comes down to talking about FM VS FRCPC the training time is literally the only thing ever compared.

If you want to bill more as a family doctor than as a specialist, you're gonna end up working much harder than the specialist, so what's the point really if you're avoiding the specialty because of the lifestyle in residency...

Sure, the residency is harder but if you can end up billing the same amount as a family doctor while working 2 days a week (which is possible in my specialty), why wouldn't you? For me, it's a good trade-off (altough I wouldn't do it because I love my specialty).

If you can see yourself doing FM, I think you should but a lot of people such as myself would rather retire than become family doctors because they don't like the type of practice that it entails and that's fine as well.

[offmychestplease]

FM can make more than peds, psych, path to name a few working the same hours. That is not "working much harder."

Secondly, you aren't taking into account the 10+ years it will take you to catch up to FM due to your triple training time (6 VS 2 years)...

 

[Monkey D. Luffy]

Well of course family medicine looks good when you compare it to all the low earning specialties lol. But at the same time I've also met a radiologist billing 300k+ (after overhead, before taxes) who takes 6 months off per year...so it is certainly possible to achieve an objectively better lifestyle as a specialist in the right specialty. People should just go into what they're interested in, specialties are wildly different from each other in the day-to-day work and 3 extra years is a drop in the bucket in the grand scheme of things imo. 

[indefatigable]

Obviously, there's no right answer.  It's pretty clear that FM generally wins out on:

• length/intensity of residency
• employment/practice flexibility

For some this easier residency aspect could be crucial especially with other concomitant life pressures.  Still, for others, training is only part of a career, and additional factors to consider include long-term career enjoyment, income, etc..  

Regarding enjoyment, FM seem to have about middling satisfaction compared to other specialists, depending on the survey (most are US-based).  Notably FM is heavier on charting/EHR use than many other medical/surgical disciplines and this seems to impact work satisfaction.  There was a recent article the Medical Post suggesting that the clerical burden has progressively increased and that an urban FP has now become part "medical secretary": https://www.canadianhealthcarenetwork.ca/family-doctor-and-medical-secretary?oly_enc_id=6234G2816812E5Z.  

In terms of income, there's a lot of variability.  In AB and ON, FPs seem to do fairly well on average, but this isn't true everywhere else.  In QC, for instance, almost all specialists (including lab, peds and psych) make significantly more than FPs which along with the relative surplus of spots, really makes it a default choice (QC is an outlier in many ways though, as training time isn't an issue when the average matriculation age is probably around 20-21).  However, my understanding of the relativity debate suggests that even accounting for additional training time, some specialties will significantly out-earn FPs even in AB/ON (radiology for example).  

 Of course then there are the subjective factors - while in theory there are a lot niches, many depend on the region (like FPA) and will not involve the same kind of practice as a RC trained specialists (e.g. surgical assist vs surgeon).  Depending on one's predilections and interests, FM generally won't offer the same kind of cutting-edge research/innovation as many specialties for instance.  As was mentioned above, FM is really 'generalist' practice and means accepting lack of depth of knowledge in many areas - but more focused on breadth.  

Ideally, all future FPs would be very interested about FM - however, there's certainly a demand/supply imbalance when it comes to matching and FM has the greatest supply (or demand depending on which way it is viewed).  I think truly embracing FM as a possible career choice from the beginning is a prudent decision - as most student do not have the option to retire early and matching to FM may be the only way to continue a career in medicine (even more necessary often due to the heavy financial burden accrued during medical school).   

[offmychestplease]

2 hours ago, Monkey D. Luffy said:

Well of course family medicine looks good when you compare it to all the low earning specialties lol. But at the same time I've also met a radiologist billing 300k+ (after overhead, before taxes) who takes 6 months off per year...so it is certainly possible to achieve an objectively better lifestyle as a specialist in the right specialty. People should just go into what they're interested in, specialties are wildly different from each other in the day-to-day work and 3 extra years is a drop in the bucket in the grand scheme of things imo. 

Peds, Psych, and path fields are some of the biggest FRCPC fields so they were used to compare not just because they are "low paying" but because they make a good proportion of FRCPC docs. Sure, we know rads/optho make way more but what % of people entering FRCPC fields really enter those fields?

Also, it's not "just 3 extra years." For most FRCPC fields you need a fellowship(s)/grad degree to land a decent job in a city so it's more like "4-5 extra brutal years". In fact even in your rads example it is a fact that it is basically required to do a fellowship (1-2 years) after the 5 year radiology residency to get any job in a city. This is after undergrad (+ any extra training before medical school), and then after medical school. Many people with the mentality that it's "just 3 extra years" and not "4-5 extra brutal years during peak age of marriage/kids etc" are the ones that get burnt out and end up very jaded before those years even finish. It's easy to say it's a drop in a bucket but living it is a different story for many people. An extra 4-5 years earning attending income and investing could make a difference where it takes 10+ years to catch up for even the more lucrative FRCPC fields....is 10 years still a drop in a bucket?

Also, there is a forum member here who was working very hard in QC (the province you mentioned with low FM pay) and was billing 600K+ in his first year out. And this was not in AB or ON. If you are motivated to work very hard and know what you're doing, you can kill in FM (since you brought up money). 

Not wanting FM because you don't like the nature of the job or you're very passionate about another field are valid reasons but not choosing FM for money reasons is a very misguided thought process once you break things down.

[indefatigable]

30 minutes ago, offmychestplease said:

Also, there is a forum member here who was working very hard in QC (the province you mentioned with low FM pay) and was billing 600K+ in his first year out. And this was not in AB or ON. If you are motivated to work very hard and know what you're doing, you can kill in FM (since you brought up money). 

I'm assuming? this comment was directed towards my post.  The forum member I believe that you are referring to was in Northern Ontario (not QC).

[MedZZZ]

It's true that you need 1-2 fellowships and/or grad degree to land a job in an urban area in lucrative specialties (e.g. GI, Cardio, Nephro, Rad); however, you can still get jobs without fellowship in other specialties like endo, rheum, allergy&immunology, and even GIM if you don't do extra fellowship/degrees. However, I don't know if the income potential for those fields justify the extra brutal 3 years and the time it takes to build up your patient base. Of course, if you are passionate about those fields, it's different story.

[offmychestplease]

2 minutes ago, indefatigable said:

I'm assuming? this comment was directed towards my post.  The forum member I believe that you are referring to was in Northern Ontario (not QC).

the guy working in Northern Ontario was billing 700K before overhead in FM - I know who you are talking about. But, the specific case I mentioned was in QC. 

[offmychestplease]

4 minutes ago, MedZZZ said:

It's true that you need 1-2 fellowships and/or grad degree to land a job in an urban area in lucrative specialties (e.g. GI, Cardio, Nephro, Rad); however, you can still get jobs without fellowship in other specialties like endo, rheum, allergy&immunology, and even GIM if you don't do extra fellowship/degrees. However, I don't know if the income potential for those fields justify the extra brutal 3 years and the time it takes to build up your patient base. Of course, if you are passionate about those fields, it's different story.

I agree with you. Those fields like endo, allergy etc actually make less than FM and need 3 extra years of training with good but not-as-good as FM job prospects.

The lucrative fields mentioned require 6-8 years of residency (yes 8 for cardio 3 years IM, 3 years cardio, 2 year sub spec) and have poor job outcomes even after completion. So it's easy to say cardio makes 2-3x FM but once you factor everything else (time involved, years lost, job market, work needed to grind all those years) it becomes a much more sobering picture with 10+ years to catch up.  

[bearded frog]

Because I would be miserable as a family doctor, not all FRCPC residencies are malignant, and if you actually enjoy your job then residency is fine? In terms of income obviously there will be FM who work hard or have a niche making more than specialists but in most circumstances if you count the same hours/patient load peds/psych will make more (I'm not familiar with pathology so can't comment on them). But it's also true that nobody goes in to peds or pysch for the money... which is probably a good thing from the patient perspective

Shitting on family vs specialty is a bad look. Everyone should consider length of training and what that training entails when choosing a specialty, and there's nothing wrong with choosing FM for that reason. Canada desperately needs more primary care and all power to those who choose that path.

[indefatigable]

13 minutes ago, offmychestplease said:

the guy working in Northern Ontario was billing 700K before overhead in FM - I know who you are talking about. But, the specific case I mentioned was in QC. 

The Ontario guy was about to bill over 700K but wasn't there yet.  Even in one of the highest paid provinces, he is grinding it out to make the big $$$.  Averages tell a different story.  

 

[offmychestplease]

And I never said it was the average. I specifically said that if you want to work very hard and know what you are doing you can really outpace many speciality fields because money was brought up. Also, average in FM is very deceiving. It does not take into account the large number of FM's that work part-time (there are not an insignificant number who work 2-3 days a week) and those not interested in maximizing earnings. 

[offmychestplease]

9 minutes ago, bearded frog said:

Because I would be miserable as a family doctor, not all FRCPC residencies are malignant, and if you actually enjoy your job then residency is fine? In terms of income obviously there will be FM who work hard or have a niche making more than specialists but in most circumstances if you count the same hours/patient load peds/psych will make more (I'm not familiar with pathology so can't comment on them). But it's also true that nobody goes in to peds or pysch for the money... which is probably a good thing from the patient perspective

Shitting on family vs specialty is a bad look. Everyone should consider length of training and what that training entails when choosing a specialty, and there's nothing wrong with choosing FM for that reason. Canada desperately needs more primary care and all power to those who choose that path.

Obviously peds will make more/patient but FM will see many more patients in a day due to the nature of the field so in a per hour (and yearly) basis it's very doable to make more in FM than peds, and to do it several years sooner with better job prospects.

[indefatigable]

2 minutes ago, offmychestplease said:

And I never said it was the average. I specifically said that if you want to work very hard and know what you are doing you can really outpace many speciality fields because money was brought up. 

You'd just be working way more hours to make up the deficit with the average practitioner in some specialty field.   Any practitioner in that specialty field could also outpace their colleagues (and the hardest working FP) by working more hours.   That's why it makes more sense to compare averages, or at least normalize by hours worked.  

[offmychestplease]

5 minutes ago, indefatigable said:

You'd just be working way more hours to make up the deficit with the average practitioner in some specialty field.   Any practitioner in that specialty field could also outpace their colleagues (and the hardest working FP) by working more hours.   That's why it makes more sense to compare averages, or at least normalize by hours worked.  

yes but average FM works less hours than the average specialist. If the FM worked the same hours as a specialist than the gap gets much less (and sometimes FM will outpace the specialist working the same number of hours). If an FM worked surgeon hours the gap would need be as wide as the averages show for example