Family Med 3 years?

[rmorelan]

1 hour ago, unmatch said:

Honestly I felt I had gained just 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.

 

Probably the same with most of us and fellowships - sure we learn some specific stuff in a particular area but overall it is just getting faster and more accurate in the area you already know with some areas of refinement.

 

[bellejolie]

agree with all of this, and heard at a province wide meeting they're just doing a formal survey to document that it is not desirable just to have it, and then it'll be squashed. so unlikely to happen anytime soon. 

[unmatch]

1 hour ago, bellejolie said:

agree with all of this, and heard at a province wide meeting they're just doing a formal survey to document that it is not desirable just to have it, and then it'll be squashed. so unlikely to happen anytime soon. 

I actually had heard that it was going to be implemented for the class entering in 2023 from a friend. Is this consistent with what you heard at the meeting?

[offmychestplease]

7 hours ago, unmatch said:

I actually had heard that it was going to be implemented for the class entering in 2023 from a friend. Is this consistent with what you heard at the meeting?

"Of significant interest is the recommendation to increase the length of training in family medicine to three years (from the current two years). More time enables programs to expand and enhance the curriculum guided by the RTP and to strengthen preparedness for comprehensive, top of scope practice. There will be no immediate change to either the CFPC’s accreditation or certification requirements regarding length of training for at least five years".

-page 7, Jan 2022, https://www.cfpc.ca/CFPC/media/Resources/Education/AFM-OTP-Report.pdf 

On page 24, "We recognize that this recommendation has substantial resource implications and potential ripple effects, requiring a slow and careful change management approach and cross-sectoral collaboration with government, university, and regulatory partners. There will be no immediate change to either the CFPC’s residency accreditation or certification standards for at least five years (2027)."

On page 28, further evidence that the next 5 years 2022-2027 will be used to create an education/accrediation task force and no changes will be implentated until 2027.

So if this ever does happen it won't impact anyone until residents starting residency in 2027, not sure why you think this could impact those starting residency next year. 

[unmatch]

2 hours ago, offmychestplease said:

"Of significant interest is the recommendation to increase the length of training in family medicine to three years (from the current two years). More time enables programs to expand and enhance the curriculum guided by the RTP and to strengthen preparedness for comprehensive, top of scope practice. There will be no immediate change to either the CFPC’s accreditation or certification requirements regarding length of training for at least five years".

-page 7, Jan 2022, https://www.cfpc.ca/CFPC/media/Resources/Education/AFM-OTP-Report.pdf 

On page 24, "We recognize that this recommendation has substantial resource implications and potential ripple effects, requiring a slow and careful change management approach and cross-sectoral collaboration with government, university, and regulatory partners. There will be no immediate change to either the CFPC’s residency accreditation or certification standards for at least five years (2027)."

On page 28, further evidence that the next 5 years 2022-2027 will be used to create an education/accrediation task force and no changes will be implentated until 2027.

So if this ever does happen it won't impact anyone until residents starting residency in 2027, not sure why you think this could impact those starting residency next year. 

Thanks for clarifying, it was just something I had heard from a friend and was asking since bellejolie had heard otherwise.

[indefatigable]

On 1/26/2022 at 9:31 PM, rmorelan said:

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). 

You've touched on some of the important issues including cost (both public and individual), training models and alternatives.

I agree that in Canada, the training model has been built almost as a pyramidal structure with the base as the "generalist" foundations.  The assumption has always been that the notion of a primary care/generalist physician occupying a certain role and adding a certain value in the health care setting - this has led to an increasingly costly training model, both from a personal and public point of view.  That role and value of the generalist are now undergoing a revision, as health care, especially in urban settings, becomes much more specialized.  

Generalists (even when demonstrably capable of providing comprehensive care as mentioned in previous post) in urban settings are arguably now providing less comprehensive care than they once did, likely as a consequence of these changes where there is increased credentialing in the form of ES for areas in which FPs used to routinely practice (where ES programs also have demand/supply mismatch).

 At the same time, other allied health professional, especially NPs, are now providing parallel care in outpatient settings.  NPs are trained at a fraction of the cost both publicly and individually with much less time in "education" broadly defined.  From what I understand there is little difference between NPs and FPs in terms of medico-legal scope in an outpatient setting, as identical investigations, consultations and treatments can be requested/ordered by both.  In other words, the base is looking less solid than it once did.  

And so the question becomes the system producing a 'good' (FP) valuable enough to justify its cost esp now when compared to alternatives?     Of course lip-service will be paid to best care etc..  but the current situation of allied-health providers spending more time with patients vs FPs who under current billing-models are under pressure to "bulk-process" many patients does not help the narrative of the necessity and value of FPs. 

Unquestionably, from a personal point of view, extraneous time/training adds cost and creates downstream pressures in terms of personal debt loads, deferred income,  etc.. and an extra year could exacerbate that.  I've argued above in both posts that extending FM by a year will not be sufficient to broadly change the role of FPs in urban settings nor result in significantly better trained FPs and potentially just risks exacerbating training/job mismatch as now seems to be occurring in the US.  

Rural/urban is clearly different, but not everyone can/wants to work rural and it's really a minority of practitioners and the population.  I don't think there should be an expectation of needing to work in a region which is far from network, family/friends etc..  Rural practicing styles do not unfortunately easily transfer to urban settings.  

I don't think there's an easy answer - but, I do think these changes/pressures will directly/indirectly affect all practicing physicians over time.  Since medical school is graduate entry (outside of QC) there's inherently 3+ years added post secondary school in terms of cost/training.  Could it mean earlier streaming for specialty training?  Does it mean changing the role of FPs to account for the changing landscape of primary care?  What about billing models?    

Edit:

random links to public discussion re NP vs GP for outpatient care (in BC seems to be a hot topic).  Commentators outside of medical field generally support NP care.  

https://www.**DELETED**.com/r/vancouver/comments/n42w5h/general_practitioner_gp_vs_nurse_practitioner_np/

https://www.**DELETED**.com/r/vancouver/comments/bpjadk/bc_hiring_200_nurse_practitioners_and_paying_them/

 

[bellejolie]

1 hour ago, unmatch said:

Thanks for clarifying, it was just something I had heard from a friend and was asking since bellejolie had heard otherwise.

 It was the opposite - that the report was being published and a survey amongst schools was going to be sent out to see the interest amongst schools (which in my province doesn’t seem to be high given the severe lack of fam docs), and then the idea would be quashed. I didn’t realize though the CFPC was actually going to release the recommendation to actually change it. If they do change their accreditation standards though, everyone will have to do it I guess!
 

Wow. I definitely think a hybrid elective/moonlighting type year with about 4-6 mandatory type rotations (generalist ones aka ER, internal, Peds ambulatory, procedures), with the other 6 months per the resident interests would be the way to do this. All of this with longitudinal staff salary paid fam med clinics throughout the year. 

[Edict]

14 hours ago, bellejolie said:

 It was the opposite - that the report was being published and a survey amongst schools was going to be sent out to see the interest amongst schools (which in my province doesn’t seem to be high given the severe lack of fam docs), and then the idea would be quashed. I didn’t realize though the CFPC was actually going to release the recommendation to actually change it. If they do change their accreditation standards though, everyone will have to do it I guess!
 

Wow. I definitely think a hybrid elective/moonlighting type year with about 4-6 mandatory type rotations (generalist ones aka ER, internal, Peds ambulatory, procedures), with the other 6 months per the resident interests would be the way to do this. All of this with longitudinal staff salary paid fam med clinics throughout the year. 

I agree with the elective/moonlighting idea. I always found it a bit odd how in Canada/US we are accustomed to the idea that you are a resident making peanuts and then suddenly you are a staff with full responsibility making big bucks. We just accept it as a fact, but I wonder how well the idea of a transitional/elective could work. 

I'm not worried about the majority of family doctors, but I worry that there is a path of least resistance in medicine that would allow someone who really doesn't intend to put much effort to make it very far without any real supervision. As of now, there is very little oversight into this, if one were to make a few missed diagnosis due to incompetent training, there is really very little that would happen in most hospitals/communities. The argument made that there's a shortage of doctors doesn't hold well among the public. We all know very well that our colleges have protected the profession well over the years (from both a dilution of the medical profession and from immigrant physicians), it isn't hard to look across the pond to find European countries where they train twice the number of doctors and where physicians make 150-200k a year. The argument has always been that by keeping our profession tightly controlled, we ensure high standards of care, that needs to continue or we risk losing that privilege. 

 

[CaRMS2021]

Peds went from being 3+2 to 4+2 as well this past year 

[zoxy]

On 1/28/2022 at 11:10 AM, Edict said:

 it isn't hard to look across the pond to find European countries where they train twice the number of doctors and where physicians make 150-200k a year.

True. But the part people forget about Europe is free medical school(except the UK), medical school starting right out of high school, a strict EU wide cap on 48 hours a week during residency, a minimum of 4 weeks of vacation, a lower patient load per doctor due to more doctors per capita, and less hours once you make attending as well. For example, attending hours in the UK are capped at 48 hours a week, in Denmark the average is 40 hours a week for attending. In most European countries, doctors get a pension upon retirement.

So take away my tuition debt, my longer training path, my residency with no work hour caps, a high patient load, and give me a 48 hour work week with a dedicated pension and I'll happily take 150K-200K.

Maybe instead of looking across the pond to the right, they public should look across the pond the to the left, meaning Australia. Or just south of the border to the USA.

On 1/28/2022 at 11:10 AM, Edict said:

We all know very well that our colleges have protected the profession well over the years (from both a dilution of the medical profession and from immigrant physicians),

I agree that the college has protected the profession, but I'm not sure the provincial governments would be able to pay for more care (not just doctors pay) even if the colleges were willing to have more doctors making less money. Despite what the public believe, physician pay isn't really a driver of healthcare costs. Gross Clinical payments to physicians in 2018-19 was 28.8 billion, while total healthcare spending stood above 250 billion in 2018-19. And that's gross clinical payments, not net. Take out 25 percent overhead and you're at 21.1 billion per year for net physician payments. So net physician pay is only 8.4 percent of healthcare spending. Even if you slashed physician pay in half, you'd save 10 billion a year. To put things in perspective, the Federal Government spent $20.2 billion on interest payments in 2020/21, Ontario spent $12.5 billion, and Quebec spent $7.6 billion. Total interest payment across the federal government the provinces was $49.6 billion in 2020/21. And those numbers are with a record low cost of borrowing. The public may think all of their tax money goes to paying doctors, but that's not the case.

 

https://www.cihi.ca/en/how-does-canadas-health-spending-compare

https://secure.cihi.ca/free_products/physicians-in-Canada-report-en.pdf

https://www.fraserinstitute.org/sites/default/files/federal-and-provincial-debt-interest-costs-for-canadians.pdf

[LoquaciousLoquat]

I think family medicine, as it is now, should be split into two separate residencies - one for exclusively outpatient / primary care, and the other for emergency / hospitalist medicine. Both residencies can still be two years, but they will cover mutually exclusive areas of practice (while both being under the scope of family medicine).

As for +1's, both tracks can access obstetrics / geriatrics / palliative care / addictions / sports medicine post training. The outpatient / primary care track can still apply for a +1 in either emergency medicine or hospitalist (similar to now) if they change their mind.

Moreover, I think family medicine should also open a recertification process open to any specialty (including Royal College trained physicians), to train for 6-12 months just in outpatient family medicine / primary care. I know many burnt out specialists would love to pivot their career towards something more lifestyle and family friendly. It would also create more family physicians. So win-win. This recertification pathway will also be open to the emergency / hospitalist medicine track as well.

I think this proposal is better than what we have now. In fact, there is already a rift in family medicine residents, often on day one, between those who want to do emergency medicine / hospital-based practice versus those who want to have a primary care / outpatient clinic based practice. A residency program that caters to both groups will often run into logistical problems (i.e. how do you balance away emergency medicine electives with your home family medicine clinic commitments), as well as professional identity problems (i.e. why tell them they'll be great family doctors when one day they'll see themselves as emergency doctors?). The knowledge base and skillset in outpatient versus inpatient / emerg are often mutually exclusive as well. So why not formalize this difference in training at the onset of residency? 

For the primary care / outpatient track, you'll now have more time to master virtually everything that can walk into your office. This means more dermatology / biopsies (a common area of weakness among family medicine grads), more psychiatry (maybe with CBT training?), more MSK / joint injections (again, due to how frequent these complaints are, we don't get enough exposure), more gyne / IUDs, more neurology (the neuro exam is another common area of weakness), and of course, more subspecialty clinics (no more questionable / bad referrals!).

Regarding the primary care board exam, in my opinion it needs far more vigour (the current CFPC primary care topics are pretty... fluffy). I suggest just taking questions out of the Royal College specialty exams, but just leave out the parts that are more acute care / hospital centered, as well as parts that require interpreting advanced testing (i.e. EMGs / echos / etc...). After all, it's the family physician who has to know how to manage obscure finding X on imaging or blood smear or physical exam or biopsy, since we're the first point of contact. There's a reason why other generalist specialties like GIM / peds arguably have higher prestige, at least within medicine - it all comes down to the intensity of their training and their expected knowledge base (both of which are far broader than family medicine).

In fact, the issues with family medicine currently: more specialization + moving away from primary care, lower compensation, midlevel encroachment, being seen as a referrologist... these can be fixed with the right training. In my opinion, what's really hurting family medicine as a whole is a lack of clear professional identity, and a training that reflects this identity. We are trained to be too many things to too many people.

Hence, having a track that focuses JUST on primary care (and leaving out emergency medicine / hospitalist medicine) is, in my opinion, the right step. It makes sense politically as well. With the rise of midlevels / NPs, we can no longer make a case that patients love their family physicians the most (since some actually like NPs more, due to accessibility / length of appointments / ease of getting tests + referrals) as political leverage. In fact, using "likeability" and other vague ideas like "being their medical home" for advocacy does not uniquely distinguish family physicians anymore (or as policy-makers might call us ... "MD trained primary care providers" *shudder*). If we are differentiated as family physicians based on our depth of knowledge and skill (as it should be), why not go all-in on this value proposition and make a residency program to reflect it? Make the case that there is no primary care "provider" better than a family physician. When a patient sees a specialist, everyone knows the specialist's opinion within their area of expertise is the bottom line. In my opinion, family physicians, at least currently, are not yet at that level. We need to be. Otherwise, we will be replaced, or perhaps worse, as being seen at the bottom of the primary care hierarchy - with specialists taking the crown in domain knowledge, and midlevels / NPs taking the crown in being "good listeners" / being likeable / relating to patients (in fact, look at the post earlier in this thread to a discussion forum, where a patient explicitly stated that her care from NPs was better than the 40+ years of care from GPs, all because of a longer appointment + more handholding). 

 

 

 

 

 

 

[indefatigable]

brackenferns' proposition makes a lot of sense and I think would help solve a number of current issues with FM practice/training in urban settings especially.  

Of course, there could be cross-over electives, and perhaps another rural stream which is more like traditional FM residency, but overall this suggestion seems to help strengthen FM through more focused training and seems to somewhat match the job market.  It's possible that the streams wouldn't be the same size or competitiveness, but I really think this out of the box thinking has the potential to really improve outcomes after training.  Plus, this may even attract more applicants as FM could be maintained as a two year program.  

[medigeek]

I think having streams that include a 3rd year is better. This allows more personalization. And even so, there should be encouragement of pursuing those streams. But I'm not sure if making everyone do it is the right answer. 

[LoquaciousLoquat]

2 hours ago, indefatigable said:

Of course, there could be cross-over electives, and perhaps another rural stream which is more like traditional FM residency, but overall this suggestion seems to help strengthen FM through more focused training and seems to somewhat match the job market.  It's possible that the streams wouldn't be the same size or competitiveness, but I really think this out of the box thinking has the potential to really improve outcomes after training.  Plus, this may even attract more applicants as FM could be maintained as a two year program.  

I agree with keeping the traditional FM residency as a rural stream. I hadn't considered rural practice in my answer but this is a good proposal.

Regarding the competitiveness + size, I think it's natural that the emergency / hospitalist stream will have more applicants and less spots. But a key point here is that applicants will self-select at CaRMS and go into a residency program with like-minded cohorts. The situation we have now is a bit... well confusing. You have emerg gunners since med school who want to apply to Royal College and have the family +1 as a backup. So these applicants claim to be interested in providing longitudinal care in family med interviews, but they don't really have the same commitment to primary / office-based care once they're in a family med program.

The current situation is bad for everyone - program directors have to filter out who actually wants family medicine versus emerg (or something else), advocacy bodies cannot craft a coherent narrative about the value proposition of family doctors in primary care (especially when fam med residents gun for +1 or specialize), mid-level providers see an opportunity for encroachment / expanding their scope into primary care, med students get confused about what family physicians actually do (saying "we do everything" is basically admitting to us not being the best / masters at anything), curriculum planners have to accommodate everyone's +1 interests (leading to higher administrative costs), patients are insecure because they never know when their future family doctor will leave their practice to specialize, and finally, family medicine residents will have to contend with an essentially divided cohort between +1 gunners (who don't actually see themselves as primary care physicians), and those that do want to provide comprehensive care.

So I say, just formalize this division already and create two (or three if we count rural) residency streams. Everyone matches to want they want out of CaRMS. They'll be in a cohort with like-minded people.

In fact, the two streams actually compliment each other very well. The primary care stream grads are the MRP / coordinators of care in the community. The emerg / hospitalists are the MRP / coordinators of care in the hospital. Both fall under the umbrella of family medicine, while taking nothing away from each other in terms of residency training, political advocacy, and professional identity.

Finally, both streams can be kept to two years. Which avoids the issue of med students avoiding a three year family medicine program and instead going into a Royal College specialty.

[indefatigable]

I agree with these suggestions.  Overall, they maintain FM's broadness of scope but appropriately narrow and deepen training to meet the demands of patients and the health care system as needed.  

There are already FM/EM integrated programs and I believe FM/hospitalist pilot programs too.  This proposal goes a logical step further by encouraging that transition in urban areas especially.  Perhaps 20-40% of FM programs would be more acute/in-patient focused whereas the rest would get more focused outpatient training.  

I also think this would help re-establish FM leadership in primary care, which i now being undermined.  FP also are in the "custodians of care" role which may mean being more judicious with investigations and referrals which also affect the overall health care system.  In contrast, NPs may simply feel they are acting as "patient's advocate" and not feel as much responsibility to the system - I believe that a branch of outpatient focused FPs would be able to better come with common standards and metrics for effectiveness and quality.  Perception of good care through  numerous investigations and referrals may not always constitute responsible care depending on the clinical context.    

I think that FM leadership isn't overly pro-active and may not be fully attuned to a forward looking proposal like this.  The reality on the ground may be changing faster than administrative decision-makers.

[medigeek]

2 hours ago, indefatigable said:

I agree with these suggestions.  Overall, they maintain FM's broadness of scope but appropriately narrow and deepen training to meet the demands of patients and the health care system as needed.  

There are already FM/EM integrated programs and I believe FM/hospitalist pilot programs too.  This proposal goes a logical step further by encouraging that transition in urban areas especially.  Perhaps 20-40% of FM programs would be more acute/in-patient focused whereas the rest would get more focused outpatient training.  

I also think this would help re-establish FM leadership in primary care, which i now being undermined.  FP also are in the "custodians of care" role which may mean being more judicious with investigations and referrals which also affect the overall health care system.  In contrast, NPs may simply feel they are acting as "patient's advocate" and not feel as much responsibility to the system - I believe that a branch of outpatient focused FPs would be able to better come with common standards and metrics for effectiveness and quality.  Perception of good care through  numerous investigations and referrals may not always constitute responsible care depending on the clinical context.    

I think that FM leadership isn't overly pro-active and may not be fully attuned to a forward looking proposal like this.  The reality on the ground may be changing faster than administrative decision-makers.

Which places have FM/hospitalist pilot programs or integrated FM programs?

[indefatigable]

23 minutes ago, medigeek said:

Which places have FM/hospitalist pilot programs or integrated FM programs?

There is a FM/EM integrated program at Dalhousie (only 4 spots).  

https://www.carms.ca/match/r-1-main-residency-match/program-descriptions/

I don't think there's anything official for FM/hospitalist, but I think it's a similar idea. 

[ChemPetE]

Great thoughts, and I love the idea of the 1 year royal college to FM pathway. Great idea for those in specialties with no employment prospects. Really should be open to those who have already done a general 'first year' in residency as if they had done a residency transfer.

Even if you have 2 separate 2 year-streams, I don't see Govt's wanting to pay for the FP premium as opposed to a FP/PA. The lower reimbursement and prospect of more 'control' over NPs I think is just too enticing

[indefatigable]

11 hours ago, ChemPetE said:

Even if you have 2 separate 2 year-streams, I don't see Govt's wanting to pay for the FP premium as opposed to a FP/PA. The lower reimbursement and prospect of more 'control' over NPs I think is just too enticing

Actually, in BC at least, NPs were effectively paid a "premium" per rostered patient.   The NP compensation was as follows:

Year 1 of the Term: $150,000 for 1.0 FTE of services  (500+ patients)

Year 2 of the Term: $155,000 for 1.0 FTE of services (800+ patients)

Year 3 of the Term: $160,000 for 1.0 FTE of services (1000+ patients)

In addition, an allocation will be provided for the NP’s overhead costs, disbursed in equal monthly installments:
$75,000 per year for rural and urban communities 

$85,000 per year for metro communities

https://divisionsbc.ca/sites/default/files/inline-files/GP Backgrounder and FAQ - Final 181023_0.pdf

for GPs it was as follows (non-rural) with no overhead:

Year 1 - 250 000$ (800+ patients)

Years 2&3 - 265 000$ (1250+ patients)

https://divisionsbc.ca/sites/default/files/inline-files/GP Backgrounder and FAQ - Final 181023_0.pdf

This is obviously not counting any increased costs due to differences in referrals/investigations.  

In other words, NPs less training/investment/debt = price premium when it comes to patient care.  

19 hours ago, brackenferns said:

Finally, both streams can be kept to two years. Which avoids the issue of med students avoiding a three year family medicine program and instead going into a Royal College specialty.

It looks like the three year FM residency is a "done deal" - it's not a question of "if", but "when" (not until at least 2027).  From what I gather, the idea is to effectively eliminate ES programs, but also pack more into the current training program.  I don't think this will address the root causes of the FM "drift" which you have identified.  

Essentially it seems the existence ES is the pretext/reason to justify a third year which seems to contain a long list of more training in areas like: Home and long-term care; Palliative care; Mental health and addiction care.; Indigenous health; Culturally safe and anti-racist care; & New technologies to improve access and continuity of care (i.e.,virtual care and health informatics).   

"We don’t think that residents should have to do additional training to be able to provide that core set of services that include things like emergency care and obstetrical care,” she said. “We think that every family doctor coming out of residency should be able to do that full scope of care.”

https://www.canadianhealthcarenetwork.ca/more-training-canadian-family-medicine-residency-expand-three-years

Logically it doesn't really make sense - more is being added and therefore there will be less focused training than in current 2+1s.  Plus, obviously it ignores all the scope of care research that I pointed out above suggesting that scope of care is almost entirely dictated by rural vs urban location and province of practice - which seem to be more important than actual training competencies (e.g. rural vs urban trained).

[LoquaciousLoquat]

I was concerned by indefatigable's link where members of the public were strongly supportive of NPs, even going so far as to say their care was better than the decades of care under their family physicians. Policy-makers listen to these people. We talk about the "FP premium", but really, what the public actually want is the "NP premium" - longer appointments, more accessible care, more handholding, and ordering more tests / making more referrals. 

I'm not concerned about being replaced. What I am concerned about, is a future where midlevels / NPs take over a sizable portion of primary care, and continue to offer a better perception of care to the public and policy-makers than FPs. At that point, we have to contend with a practice environment that is even more hostile and derisive to our profession than it is now. The media will be drawing analogies between the "boutique, personalized, premium" care of NPs / midlevels, as opposed to the "fast-food, assembly care" care of FPs. The policy-makers will leverage public sentiments to further depress our wages. Patients will become more demanding, or just outright complain that they "only" have an FP instead of an NP who "actually listens to them". The non-primary care physicians will look at all this and breathe a sigh of relief they didn't choose our specialty. And amidst all this, FPs are still the ones who primarily have to put in the (sometimes unpaid and usually thankless) hours to keep our healthcare system afloat.

The core issue, as I see it, is that physicians no longer have the final word in ambulatory / primary care. The causes are multifactorial: increasing specialization in family medicine, residency programs that have to cater to all the +1's, a lack of rigour in family medicine training (at least compared to GIM / general peds), a lack of clear professional identity (to see us as a unique specialist in ambulatory primary care), and perhaps more importantly, a lack of political will and insight on what needs to be done. 

1 hour ago, indefatigable said:

It looks like the three year FM residency is a "done deal" - it's not a question of "if", but "when".  From what I gather, the idea is to effectively eliminate ES programs, but also pack more into the current training program.  I don't think this will address the root causes of the FM "drift" which you have identified.  

I agree. It's concerning because there is a very low-hanging fruit to be had by creating a family medicine residency stream to specifically train specialists in ambulatory primary care (i.e. the outpatient version of internists). Having a focused residency stream will create the public perception that physicians see primary care as a top priority - rather than as an afterthought to the already growing list of competencies a family physician is expected to perform. This will also restore physician leadership in primary care, increase our bargaining power, and reignite public confidence. The fact there is not a dedicated residency program specifically to train physicians for what is arguably the most important and high-need area of healthcare is, well, rather inexcusable. It just fuels the public perception that us physicians "don't care about patients" or that we think we're above (or just too greedy) to go become their primary care physician. It's also politically difficult to ask for more funding in family practice when we spend the same resources to train family residents away from primary care and into specialties and +1s.

 

 

 

 

 

[offmychestplease]

I don't get it

 

[LoquaciousLoquat]

34 minutes ago, offmychestplease said:

I am genuinely curious how much of the general public knows the MASSIVE difference in length of training, intensity of training, barrier to entry, etc. of MD VS NP?

The public by and large doesn't care. They want longer appointments, more accessible appointments, more handholding, and someone to give them what they want. 

There is also a growing problem where the general public does not respect the FP's word on a medical issue.  If a specialist denied them treatment, patients know that's the final word, and they won't argue about it (as much). But if an FP doesn't want to order the thyroid panel their naturopath suggested? Well, who is this FP to tell them what to do? After all, the patient knows their body the best; endocrinologists know the science the best. FPs don't have the final word on anything. The patient want the bloodwork, now!

And frankly? Family physicians have, in a way, created this problem ourselves, by insisting that we remain a "jack of all trades" instead of streamlining our training to better reflect our future practice. If we are exclusively trained to be a specialist in out-patient primary care, then we would have more time to get confident, make less referrals, and have more political leverage to negotiate better practice models where we get fairly compensated for our time. But it doesn't look like the CFPC wants to head in that direction...

[Premed 24/7]

39 minutes ago, offmychestplease said:

I am genuinely curious how much of the general public knows the MASSIVE difference in length of training, intensity of training, barrier to entry, etc. of MD VS NP? just a fyi, you can become an NP in Canada via a 18 month online US NP degree (with no RN experience needed) that literally have 100% acceptance rates where half the degree is literally writing essays on healthcare topics while being able to work part-time for one...

Even Canadian NP programs are in no way close to the rigor and barrier to entry of medical school + residency ...

 

Never mind the general public, vast majority of med students dont even know about NPs scope creep / their lack of eduction.

[gogogo]

2 hours ago, brackenferns said:

The public by and large doesn't care. They want longer appointments, more accessible appointments, more handholding, and someone to give them what they want. 

There is also a growing problem where the general public does not respect the FP's word on a medical issue.  If a specialist denied them treatment, patients know that's the final word, and they won't argue about it (as much). But if an FP doesn't want to order the thyroid panel their naturopath suggested? Well, who is this FP to tell them what to do? After all, the patient knows their body the best; endocrinologists know the science the best. FPs don't have the final word on anything. The patient want the bloodwork, now!

This is one of the major concerns I have with entering FM (note: CaRMS is done, all my applications are to FM, and at least for now, I intend on a community clinic practice). How much of this is a regular problem for you vs. having a minority of bad apples you know you'll have to deal with once a week or so? All specialties have frustrating and demanding patients, but of course, FM gets the most of it. I'm just thinking (well, hoping) that if I can develop a roster and get to know my patients, that such entitled patient behaviour can be mostly avoid/controlled.

 

P.S. Amazing insights on the future of FM--it's given me a lot to think about.

[bellejolie]

6 minutes ago, gogogo said:

This is one of the major concerns I have with entering FM (note: CaRMS is done, all my applications are to FM, and at least for now, I intend on a community clinic practice). How much of this is a regular problem for you vs. having a minority of bad apples you know you'll have to deal with once a week or so? All specialties have frustrating and demanding patients, but of course, FM gets the most of it. I'm just thinking (well, hoping) that if I can develop a roster and get to know my patients, that such entitled patient behaviour can be mostly avoid/controlled.

 

P.S. Amazing insights on the future of FM--it's given me a lot to think about.

residency practices are notorious for being much more difficult than a baseline regular community practice. it's not representative. lots of my friends did community practice in their rural rotations and loved it. the resident practices contain more challenging patients who many staff have shifted over because they "don't wnat to deal with them" and such. community practice still has a lot of rewarding things, and every specialty will have difficulty and challenging patients.

NPs will never be able to see as many patients as family docs do, and that'll eventually become clear. sure patients might like they get an hour, but that means NPs are seeing 10 patients a day. Our staff see 30-40 in a day. also anything outside their algorithms they have no idea how to handle, so again i'm not worried. NPs are useful for simple one issue things like UTIs and can help alleviate the burden for those kinds of things, similar to pharmacists. however there's no chance they can really take over. ridiculous they're getting paid that much (what i saw above).