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Family Med 3 years?


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Yes. But many many factors to consider - firstly funding (it’s an extra year of residency provinces will need to fund), in addition they lose a whole year of grads, which esp in fam med is really not ideal, and also how they’re going to fill that year - ultimately it will make us better fam docs I think, but one of my supervisors said they might look to a hybrid training/moonlighting type year so that they don’t lose people who can actually work and serve the community. I heard u of t will be first Guinea pigs to try it soon ish but no idea timeline or anything like that. Just a lot of factors to consider. 

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7 hours ago, bellejolie said:

Yes. But many many factors to consider - firstly funding (it’s an extra year of residency provinces will need to fund), in addition they lose a whole year of grads, which esp in fam med is really not ideal, and also how they’re going to fill that year - ultimately it will make us better fam docs I think, but one of my supervisors said they might look to a hybrid training/moonlighting type year so that they don’t lose people who can actually work and serve the community. I heard u of t will be first Guinea pigs to try it soon ish but no idea timeline or anything like that. Just a lot of factors to consider. 

They gain a year of cheap labor.

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Granted, I don't have a leg in the game but I always thought a 2 year FM residency is a bit too short given what we task our family physicians to do (i.e. be the jack of all trades in rural areas). I've never seen a country where one could feasibly become a fully licensed physician in just 5 years (3 yr MD + 2 yr FM). Most of my friends in family medicine confide they don't exactly feel ready the moment they graduate. Even after my first 2 years I certainly did not feel ready to be independent with pretty much anything. 

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4 minutes ago, Edict said:

Granted, I don't have a leg in the game but I always thought a 2 year FM residency is a bit too short given what we task our family physicians to do (i.e. be the jack of all trades in rural areas). I've never seen a country where one could feasibly become a fully licensed physician in just 5 years (3 yr MD + 2 yr FM). Most of my friends in family medicine confide they don't exactly feel ready the moment they graduate. 

Luckily in FM, nothing is ever rarely urgent, and you can take your time working things up and gaining more and more knowledge as you see patients and work with specialist colleagues.

A colleague had applied for extra training in addictions (not the full year, but the partial 3 month program) and was denied due to lack of space. So I don't know Where are they finding space to keep residents for another full year?   

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I get that most FM is non-urgent. And additionally, put a passionate and keen self driven learner anywhere and they will succeed, but the name of the game in medicine is setting ourselves a high standard. We want the public to be able to trust their physician and family physicians are the QB of medicine, arguably the most important player. 

If we think of the bottom end, the reality is that the potential for incompetence is there. Mac grads sometimes get a bad rep for variable training, and part of that is the curriculum is so flexible. The amount of mandatory class is 9 hours a week of which only 6 are medical topics. Throw in a shortened 3 year program and a near guarantee that you will match to a residency in Canada the only real next bar is the CCFP exam (The LMCC pt 1 is a bit of a joke).

Now I'm not a staff physician and I don't want to comment on everything, but specialty residents complain of inappropriate referrals from emerg and I have seen staff surgeons receive many criticalls that were not appropriate. 

I remember this emerg doc out rurally (2 year FM) who couldn't identify any of the major types of intracranial bleeds on CT at a course, and they had been practicing for decades. This wasn't the only thing they seemed to not know and they actually got pulled from the course. At the time, that blew my mind. Perhaps, some form of semi independent practice or electives based 3rd year would be appropriate. 

This is a great opinion piece to read: https://www.cfp.ca/content/58/9/1045

 

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Making FM residency 3 years takes away one of best things about FM. There's even less reason to pick FM. It does create more jobs and relevance for senior FMs high up in their academia ivory towers.

I'm all for making FM 3 years if they split it like this: a year of emerg, a year of CTU and ICU, and a year of outpatient clinics and OB. All new grads would come out competent to practice general medicine in any of these settings. There's no way cfpc would do something logical like this.

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I think a substantial number of med students interested in FM would just pursue a specialty instead if they made FM 3 years (myself included). Consider how many non-trads (who tend to be older) enter the field knowing from the beginning that they're pursuing FM--part of that is because of the shorter training.

FM is great and all, but one great aspect is how you can avoid a 4/5-year residency. FM comes with a ton of responsibility and on average lower pay compared to specialties, so something needs to keep the incentives balanced. If by making it a 3-year residency, they also increased the ability of being paid fairly while still practicing good medicine (e.g., by increasing FHO spots), then I think it would compensate. They could also increase the checks and balances during residency to ensure that competent physicians come through the pipeline.

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4 minutes ago, gogogo said:

I think a substantial number of med students interested in FM would just pursue a specialty instead if they made FM 3 years (myself included). Consider how many non-trads (who tend to be older) enter the field knowing from the beginning that they're pursuing FM--part of that is because of the shorter training.

FM is great and all, but one great aspect is how you can avoid a 4/5-year residency. FM comes with a ton of responsibility and on average lower pay compared to specialties, so something needs to keep the incentives balanced. If by making it a 3-year residency, they also increased the ability of being paid fairly while still practicing good medicine (e.g., by increasing FHO spots), then I think it would compensate. They could also increase the checks and balances during residency to ensure that competent physicians come through the pipeline.

True...I suppose the major issue though is whether 2 years is enough time - after all the primary concern of the college is making sure people truly are trained well enough to do that job. Ultimately nothing else will really matter to them. One long term problem we have in medicine is simply ALL specialities are requiring us to learn more and more in the same amount of time - at some point something has to give. Right now that is fellowships - which have shifted over time from being relatively rare to basically completely required for a lot of fields, and often more than one for that matter (my specialty training was not 4/5 years - it was 7. As an example almost all radiologists are at 6 for the same job that used to be 5). The overall impact is in a sense an extension of residency without calling it that - because actually making residency longer would shall we say "unpopular". You can deal with that by reducing the scope of what people need to know (by becoming more subspecialized) or by increasing the time of training. Either way there are significant downsides for people.  You could also potentially find a way to make residency training more efficient which also as issues as most options there reduce involvement in clinical work that is important but lower yield - the hospital system needs people to just do things in order to operate). 

They also have a bit of power move that is always in the background- there is always a fix number of positions out there, and most of the non-family med specialities completely fill. Effectively changing it to 3 years would probably make a lot more grumpy people but not actually change much the number of people going into the field ultimately. It's a zero sum game. 

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39 minutes ago, rmorelan said:

True...I suppose the major issue though is whether 2 years is enough time - after all the primary concern of the college is making sure people truly are trained well enough to do that job. Ultimately nothing else will really matter to them. One long term problem we have in medicine is simply ALL specialities are requiring us to learn more and more in the same amount of time - at some point something has to give. Right now that is fellowships - which have shifted over time from being relatively rare to basically completely required for a lot of fields, and often more than one for that matter (my specialty training was not 4/5 years - it was 7. As an example almost all radiologists are at 6 for the same job that used to be 5). The overall impact is in a sense an extension of residency without calling it that - because actually making residency longer would shall we say "unpopular". You can deal with that by reducing the scope of what people need to know (by becoming more subspecialized) or by increasing the time of training. Either way there are significant downsides for people.  You could also potentially find a way to make residency training more efficient which also as issues as most options there reduce involvement in clinical work that is important but lower yield - the hospital system needs people to just do things in order to operate). 

They also have a bit of power move that is always in the background- there is always a fix number of positions out there, and most of the non-family med specialities completely fill. Effectively changing it to 3 years would probably make a lot more grumpy people but not actually change much the number of people going into the field ultimately. It's a zero sum game. 

As a non-trad currently going through it, 2 years doesn’t feel like it’s enough to be a strong generalist, but I don’t actually think making it 3 years will fix that. People are moving away from general family medicine and towards niche areas of family practice or inpatient/emerg for many reasons. It is becoming harder and harder to know enough to actually do true full-scope practice. More relevant is that it is EXHAUSTING to be a doctor who does everything - I work with docs like that, and they have no work life balance - and it doesn’t tend to pay that well. And because of that, people often behave like crappy doctors or make mistakes because the current system incentivizes rushing. I think there’s plenty of ‘bad’ doctors out there who could do better under different circumstances, and I don’t think extra training will fix that. ESPECIALLY if it doesn’t come with a pay raise to account for the extra year of training or better support for community practices.

I think it might make more sense if we had something like the extra year in IM, where you could opt to do some extra general training for 6-12 months OR apply for CaRMS +1 OR just stop, and we expanded the options to available (as opposed to only the current +1 programs). But even then, part of what drew me to family was the option to retrain later in my career to be more specialized. I would have seriously considered a speciality if FM was a mandatory 3 years. 

Edited by frenchpress
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1 hour ago, 1029384756md said:

Making FM residency 3 years takes away one of best things about FM. There's even less reason to pick FM. It does create more jobs and relevance for senior FMs high up in their academia ivory towers.

I'm all for making FM 3 years if they split it like this: a year of emerg, a year of CTU and ICU, and a year of outpatient clinics and OB. All new grads would come out competent to practice general medicine in any of these settings. There's no way cfpc would do something logical like this.

If they split it like that, by the time I was done my year of OB and outpatient, I would have forgotten everything about CTU and ICU. Or vice versa. People get good at what they’re doing, and they forget what they aren’t doing. I think part of what actually makes the better 2yr family med programs out there work well is that you spend a lot of time doing family and minimal time doing other less relevant rotations, and then you finish and you start working and keep applying what you learned. More CTU will not make me a better family doctor. More OB also won’t make me a better family doctor, because I have no intention of doing deliveries. But it would provide a heck of a lot more cheap labour to the medical system. 

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I find it amusing that our Family Medicine physicians want to increase residency training times, meanwhile our nurse colleagues want to get their NPs to pay parity with GPs with a fraction of the clinical training. Who is this really for? Certainly not the payer, the government doesn't seem to think there is a difference between a GP and an NP as they happily raise salaries for NPs and chase out full service GPs to Hospitalist work (at least in BC).

If the extra year is implemented then there needs to be some lobbying or action of this issue as well. At the very least they need to convince governments that this is actually worth it (when right now it appears they barely think training GPs are worth it). Otherwise it makes much more sense for the average applicant to just do the NP route and save yourself the headache.

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2 years is just too short, no if and or buts about it. Family Medicine training is 3 years in the US. On the other hand, other specialties may be training for too long as Emerg Anesthesia Internal and Peds are 3 years as well. Family Medicine needs to know the broadest material out of any other physician, why would their training be half to a third of the length ??

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49 minutes ago, CaRMS2021 said:

2 years is just too short, no if and or buts about it. Family Medicine training is 3 years in the US.

This isn't a good enough argument to make training longer.

It is all about practice style. In the 3 year US training model: If you don't plan on doing obstetrics - then those 4 months of ob deliveries in residency is useless. If you don't do inpatient care, being as grunt worker on the ICU rotations for 3-4 months is useless.  Doing more than a month of general surgery? Useless in the majority of scenarios(a month is more than enough with 1:3 call to become proficient at identifying the major surgical abdomens and when you need to be getting the patient to a general surgeon.).

For those who want to work in certain settings: provide more opportunity to get an extra year of training! Many colleagues who wanted to do extra work in addictions, emerg, hospitalists etc, were denied extra training opportunities due to lack fo training space.  Let people pick what they want more in.

In urban centres, the days of the FM doc doing clinic, hospitatlist, emerg, ob, and geriatrics all in one..are mostly gone - for good reason; its too difficult to maintain skillsets across the board effectively, and not financially or emotionally sustainable either.    If im going into the emerg, I want someone who spends all day every day doing that for their career, not someone who comes in once in a while for a few shifts in a podunk mid-sized centre. If im being admitted under a hospitalist - i want someone who spends the majority of their time in the hospital, knows how to navigate the resources, and knows when to get back up support with IM/ICU. Yes, many are competent practicingin different scopes, but that is all on the individuals ongoing education - not that they did 2 or 3 years of training, often in exta areas that dont help them in their day to day.

People are too focused on length of training and ignoring the fact that you learn more in your first few years of practice than you often do in your whole 2 years of FM residency, when you filter out all the stuff you don't incorporate into your practice.  

You can't want a family doc to be able to do it all, but yet don't support them to actually be doing it in real life practice. Can I handle insulin starts, complex diabetic education etc? Yes, I have and  its dead easy. But if theres an endocrionologist who will happily take over, bill 5x as much to see the patient, and theres diabetic nurse educators that can spend an hour with the patient..what do you think im picking? 

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The 2 years is sufficient, because urban FM practices primarily outpatient FM care.

I do see what everyone else is saying about hospitalist/ER though. The local radiology residents complete as many IM & ER rotations as the local FM residents, and I wouldn't want a radiology resident as my ER or hospitalist doc. You need airway skills & the ability to run a code to practice ER/hospitalist medicine safely in a small centre where you may be the only doc around. I would hope that new FM graduates practicing in these areas complete some extra electives or do a +1 enhanced skills program.

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The way I see a 3 year program running would be a minimum 3 years with the 3rd year primarily electives driven. The current +1 enhanced skills programs could be rolled into this in such a way that a +1 would count as your 3rd year. A primarily family practice based oriented 3rd year could even offer opportunities to locum or practice in a JA style role, allowing for higher pay.  

The argument for saying you learn just as much on the job as in residency is a fair point, but is it any different from me saying I should become a staff surgeon now and just figure it out on the job? I probably could, however i'm pretty confident that i'd have a fair number more serious complications if I started staff now rather than when I have completed my fellowship training. The further I go on in residency the more I've realized how much there still is to learn. 

While I understand the concern over an additional year, it really is just an additional year. Most specialty residents know that training these days rarely ends with graduation from residency, so rarely is anyone these graduating and finding a job in 4/5, it is usually somewhere closer to 6-7. 

I also absolutely agree that extending family medicine to 3 years should serve as a rebuttal to any notion that NPs can do a primary care physician's job. 

I think the suggested variability when it comes to family doctors and the common notion that there are "good" and "bad" ones is a problem, having 3 years I think would help residents gain more confidence as well before stepping out into practice. I hear a lot of talk from family residents about how they sometimes feel pushed out there and not exactly prepared. With the ever increasing amount of information burden, knowledge burden, its no wonder why they feel that way after 2 years. 

 

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Unfortunately, I don't think a mandatory third year of FM training will be a silver bullet to many of the issues facing FM including scope creep, niche practices,  administrative burden & billing pressures, etc..  

Even though the US has 3 year FM, scope creep down there is even more common.  There's no turning back the clock to the way things used to be - midlevels are here to stay and the notion of primary care has moved away from being exclusively the domain of a physician.  NP run clinics are opening up nationwide for example and a three year FM residency won't change that.  

While it's nice to imagine that somehow a third year will allow better training and more choice for FM residents, I doubt that will occur.  Likely people who want concentrated practices in a single area like anesthesia or ER will gun for it anyways, and may resent having to do service in non-related rotations (those services will be happy with the extra set of hands though).  Instead of getting a better residency training, they may end up with a more diluted experience which certification bodies could object to - that's assuming that somehow there would be enough ER and related rotations to satisfy demand... or maybe access will be inequitably distributed, etc..  

As others have mentioned, the issue is deeper than this, because the concept of a full scale generalist really only exists in non-urban communities (where the population size is too low to be able to support broader services).  Focused practice, like in other areas, is becoming the norm.  Afaik, low-risk OBs is rarely done by new FPs outside of QC or rural areas for example - yet rotations are mandatory for all FM residency programs- so further training may be mismatched to the actual job/skill market of what FPs do in most urban centers (where most of the population is).

 To add to this, as was mentioned, even with the knowhow, there isn't much motivation for FPs to manage complex conditions given the billing codes (FHO/FHTs are somewhat of an exception) which generally incentivize managing relatively healthy patients in an expeditious fashion.  And lastly, further incremental exposure in some areas would be unlikely to change the broader management picture where referrals, extensive charting, are much more of a necessary part of the practice landscape.  FPs are scope-limited - not only procedurally and surgically, but also medically with more advanced treatments like biologics.. which their patients may need.   

 

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Specialist perspective here. I think if moving to 3 year program there needs to be a recognition of increased reimbursement to account for opportunity cost here (which govt will never voluntarily fund). Med students will clearly compare 3 and 4 year training programs and lifetime reimbursements, and fewer people will voluntarily seek to do primary care when the system needs to dramatically increase primary care physician access.

 I agree with above where there is already a bottleneck on FP training spots available, it is a disservice to those that after 2 years that can safely transition to independent practice. Isn’t that one of the aims of CME, as well as moving to the CBD model of education? All this does is delay a full year’s attending’s wage to already indebted grads. I would challenge that if you compared a graduate from a 2 vs 3 year program 2-3 years out you would not find a difference in outcomes. Rather, we are seeing govts actively disincentivize primary care with NP vs FP reimbursement, when we are at a point where the US starting to see differences in cost and quality of care at a systems level from the differences in providers. Our system can’t afford poor primary care access and care - it only costs the system more due to delayed and unmanaged/undermanaged chronic diseases that need costly acute interventions later on in life. I welcome other perspectives, but a third year of residency I don’t think changes that, especially when NPs are becoming more common with less training.

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17 hours ago, Edict said:

The way I see a 3 year program running would be a minimum 3 years with the 3rd year primarily electives driven. The current +1 enhanced skills programs could be rolled into this in such a way that a +1 would count as your 3rd year. A primarily family practice based oriented 3rd year could even offer opportunities to locum or practice in a JA style role, allowing for higher pay.  

The argument for saying you learn just as much on the job as in residency is a fair point, but is it any different from me saying I should become a staff surgeon now and just figure it out on the job? I probably could, however i'm pretty confident that i'd have a fair number more serious complications if I started staff now rather than when I have completed my fellowship training. The further I go on in residency the more I've realized how much there still is to learn. 

While I understand the concern over an additional year, it really is just an additional year. Most specialty residents know that training these days rarely ends with graduation from residency, so rarely is anyone these graduating and finding a job in 4/5, it is usually somewhere closer to 6-7. 

I also absolutely agree that extending family medicine to 3 years should serve as a rebuttal to any notion that NPs can do a primary care physician's job. 

I think the suggested variability when it comes to family doctors and the common notion that there are "good" and "bad" ones is a problem, having 3 years I think would help residents gain more confidence as well before stepping out into practice. I hear a lot of talk from family residents about how they sometimes feel pushed out there and not exactly prepared. With the ever increasing amount of information burden, knowledge burden, its no wonder why they feel that way after 2 years. 

 

I totally agree with all of this, especially how you describe the third year being and I think if they do it, it’ll have to be like this with moonlighting/hybrid model applied so it still motivates students to apply to family. 

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In the current environment where there are severe shortages in GPs where it’s impossible to find one in some areas within a reasonable timeline, and the gov is resorting to hiring IMGs or having NPs replace Canadian trained physicians, it makes no sense to disincentivize further students from pursuing family med. Family med spots already go unfilled so I don’t know what the academic faculties are thinking by extending it by another yr. Never mind the fact that the older physicians themselves all only had to do a 1 yr internship before getting to be a GP.


If two yrs isn’t enough to prep physicians, then maybe they should mandate all the older docs to have to go back and complete two more yrs of residency to finish 3 yrs. And if their reasoning is that they don’t need more training because they have learned from yrs of clinical practice, then that is exactly the reasoning why the family medicine shouldn’t be extended, as attendings learn on the job and it’s unfair for the older generation to get to have that privilege but not the younger generation.

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I looked at a few papers to understand the effects of differences in training on scope of practice (likely related to "confidence"),.. for FPs  This can also give an indication of what a mandatory third year of FM could best change in terms of practice styles.  

First paper (from 2018) showed that rural training significantly trumps urban training for scope of practice in both urban and rural settings.  But urban graduates in rural settings had a much greater scope of practice than rural graduates in urban settings.  In other words, urban settings are likely just limited in terms of being a "generalist".  With the explosion in medical knowledge, advances in procedural/surgical and medical treatment,  (sub-)sub-specialization in urban settings there's simply less of a role for broad, comprehensive care.  A third year of FM training won't change that. 

https://www.rrh.org.au/journal/article/4514

Next paper (from 2010) suggests that differences in scope of practice are indeed almost entirely explained by: i) rural vs urban setting (in part because of decrease access to specialists) and ii) province of practice.  Other factors increasing scope were alternatives to exclusive fee-for service renumeration, group practice and integration of other allied health professionals.    

https://www.cfp.ca/content/cfp/56/6/e219.full.pdf 

Finally, wrt to the US, there's actually been a marked decreased in terms of scope of practice vs training - i.e. FM residents are being trained for roles/skills which they can't/don't need/use - the classic "cart before the horse" fallacy.  Even more surprising,  is there has actually been a decline of FPs providing basic services like chronic disease management, preventative health... (?scope creep).  Unfortunately, the simple "more years of training = better = more pay" is part of an "academic fallacy" (I should likely be on a superyacht by this point ha).  

https://www.jabfm.org/content/31/2/181?ijkey=86bc9af0498dcf2adc6a8e3878110bffcbaaf316&keytype2=tf_ipsecsha

https://www.jabfm.org/content/31/2/178.short

In conclusion, I think the issues are much broader than simply adding an extra year of FM training.  Maybe FP should be re-imagined, taking into account the realities on the ground and somehow additional FM training could be part of it - but understanding how to best use FM training in a urban setting, what are best payment systems (the classic two problems in 10 minutes may not be the best way to use FPs), interprofessional relationships, needs to be all worked out.  The "cart before the horse" doesn't work.  

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Honestly I felt I had gained most of my family med competency for outpatient practice by the end of first year. Second year was more about gathering speed. I feel that you learn the most when the training wheels are off in practice. Adding another year of residency with the training wheels on will have diminishing returns.

 

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On 1/23/2022 at 8:57 PM, indefatigable said:

Unfortunately, I don't think a mandatory third year of FM training will be a silver bullet to many of the issues facing FM including scope creep, niche practices,  administrative burden & billing pressures, etc..  

Even though the US has 3 year FM, scope creep down there is even more common.  There's no turning back the clock to the way things used to be - midlevels are here to stay and the notion of primary care has moved away from being exclusively the domain of a physician.  NP run clinics are opening up nationwide for example and a three year FM residency won't change that.  

While it's nice to imagine that somehow a third year will allow better training and more choice for FM residents, I doubt that will occur.  Likely people who want concentrated practices in a single area like anesthesia or ER will gun for it anyways, and may resent having to do service in non-related rotations (those services will be happy with the extra set of hands though).  Instead of getting a better residency training, they may end up with a more diluted experience which certification bodies could object to - that's assuming that somehow there would be enough ER and related rotations to satisfy demand... or maybe access will be inequitably distributed, etc..  

As others have mentioned, the issue is deeper than this, because the concept of a full scale generalist really only exists in non-urban communities (where the population size is too low to be able to support broader services).  Focused practice, like in other areas, is becoming the norm.  Afaik, low-risk OBs is rarely done by new FPs outside of QC or rural areas for example - yet rotations are mandatory for all FM residency programs- so further training may be mismatched to the actual job/skill market of what FPs do in most urban centers (where most of the population is).

 To add to this, as was mentioned, even with the knowhow, there isn't much motivation for FPs to manage complex conditions given the billing codes (FHO/FHTs are somewhat of an exception) which generally incentivize managing relatively healthy patients in an expeditious fashion.  And lastly, further incremental exposure in some areas would be unlikely to change the broader management picture where referrals, extensive charting, are much more of a necessary part of the practice landscape.  FPs are scope-limited - not only procedurally and surgically, but also medically with more advanced treatments like biologics.. which their patients may need.   

 

Still have the paradox going on there - where a generalist is most useful - more rural practice which population wise is still relatively smaller population pool is also for many are less desirably areas. Adding a year of training people will make that worse as well - there are other factors in play here - they longer your you are working in urban areas the more likely you are going to stay there (for one thing people often find a partner there who has their own career already going in that city). You can never separate out these staffing issues from the broader context of things. Doing more training without access to any additional income down the line isn't exactly a great sell either - there is a real cost to doing extra years of training. 

Medicine is generally riff with mismatch of skill training to the actual job - medical school is always trying to train "generalists" but the majority of us simply aren't and use only a fraction of the training (time consuming and expensive training). Objectively it really is highly inefficient in places (you could argue the entire model is outdated - and there are fields that could be separated out and trained better separately. A major argument against this is you would have to know what field you wanted to do prior to starting medical school which is not true for most but medical school is often poorly designed to let you do that either (for instance not at all uncommon to have to pick 4th year electives for CARMS prep prior to even doing your clerkship rotations in those areas, and your clerkship order is not designed in most places to let you select from a list of fields you narrowed down. We really don't make a major focus on helping people pick a specialty and get it either - it comes up but is not woven into most medical school curriculums as a core function). 

 

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