Family Med 3 years?

[indefatigable]

46 minutes ago, medigeek said:

But the absolute percentage is still pretty low. Also a lot of it depends on your exact setting (established practice vs walk in) and how knowledgeable your patients perceive you to be. Are you confidently performing workups and getting the answers for the patients or are you quickly referring? Patients only request referrals due to prior practice patterns anyway. 

Indeed.  I have been told by very experienced FPs that patients who are used to frequent referrals/specialized care (available large metro centres) expect that level care and are disappointed when such care is not feasible.  

[Edict]

8 minutes ago, medigeek said:

The US is a model of the future for Canada. Midlevels get independent practice rights in all specialties in all states and also are now going to be immune from lawsuits. No one will see them as an inefficiency. The only path forward for them is increasing privileges. 

Not so fast, biggest difference between the US and Canada is our healthcare system. In the US, private healthcare means that patients get what they want when they want it but at a price. The patient is more in the driver's seat in the US. NPs there provide a valuable service without medical knowledge, why? Because patient satisfaction is #1, a happy customer is a paying customer. NPs are proliferating because the patient doesn't know any better, and threads like the one posted here are exactly why. Patients are happy with their care (they may be paying more for it through their insurance premiums, co-pays and deductibles, but they won't see it and won't know it). 

However, Canada is different, from a government's perspective, the patient is the problem. Expensive patients are bad for the system. They want to cut costs without harming outcomes, but the outcomes they care about are not patient satisfaction, its mortality and morbidity. This is one major reason why NPs do not have the same privileges here compared to the US and also why I don't think NPs will be gaining those same privileges soon. If NPs are ordering unnecessary tests and unnecessary consults and take 1 hr to see a patient it took a GP 10 minutes to see, that is potentially much more expensive than the added cost of paying a doctor. Specialists aren't complaining of course because a quick, easy, consult is easy money, but from the government's perspective, they don't like this one bit. 

 

 

[medigeek]

2 minutes ago, Edict said:

Not so fast, biggest difference between the US and Canada is our healthcare system. In the US, private healthcare means that patients get what they want when they want it but at a price. The patient is more in the driver's seat in the US. NPs there provide a valuable service without medical knowledge, why? Because patient satisfaction is #1, a happy customer is a paying customer. NPs are proliferating because the patient doesn't know any better, and threads like the one posted here are exactly why. Patients are happy with their care (they may be paying more for it through their insurance premiums, co-pays and deductibles, but they won't see it and won't know it). 

However, Canada is different, from a government's perspective, the patient is the problem. Expensive patients are bad for the system. They want to cut costs without harming outcomes, but the outcomes they care about are not patient satisfaction, its mortality and morbidity. This is one major reason why NPs do not have the same privileges here compared to the US and also why I don't think NPs will be gaining those same privileges soon. If NPs are ordering unnecessary tests and unnecessary consults and take 1 hr to see a patient it took a GP 10 minutes to see, that is potentially much more expensive than the added cost of paying a doctor. Specialists aren't complaining of course because a quick, easy, consult is easy money, but from the government's perspective, they won't like the bill. 

 

 

I mean the patient is just as much in the driver's seat in Canada as they are in the US. In fact, it's much easier to doctor shop in Canada. I do agree patients not knowing any better is the problem but I'm not sure how Canada is much different? There might be some small difference in more patients wanting a doctor but I highly doubt it's that significant. Canada also has a more educated population vs the US. People with a higher level of education are more likely to want that "customer service" aspect as well. 

I still wouldn't underestimate midlevel lobbying. Buzzwords and talking points like "access to care" eventually gain traction. They can be completely false but they can and do gain traction. What happens when NPs are seeing your GI or endo referrals for the first time? In the US, it's quite common for a complex liver patient for example to be seen only by a PA or NP even after extensive workup. 

[Edict]

https://www.**DELETED**.com/r/nursepractitioner/comments/an5m3t/nurse_practitioner_vs_medical_doctor_md_do/

Came across this interesting thread actually, surprised to read and find a lot of NPs would have chosen med school if they could and several seem quite aware of their lack of training. Just some food for thought on that issue, but understand this isn't the topic at hand.

 

[Edict]

11 minutes ago, medigeek said:

I mean the patient is just as much in the driver's seat in Canada as they are in the US. In fact, it's much easier to doctor shop in Canada. I do agree patients not knowing any better is the problem but I'm not sure how Canada is much different? There might be some small difference in more patients wanting a doctor but I highly doubt it's that significant. Canada also has a more educated population vs the US. People with a higher level of education are more likely to want that "customer service" aspect as well. 

I still wouldn't underestimate midlevel lobbying. Buzzwords and talking points like "access to care" eventually gain traction. They can be completely false but they can and do gain traction. What happens when NPs are seeing your GI or endo referrals for the first time? In the US, it's quite common for a complex liver patient for example to be seen only by a PA or NP even after extensive workup. 

Yes, we definitely need to ensure appropriate training equals appropriate roles. I think its illogical for me to argue for a 3 yr fam med residency and be okay with NPs practicing family medicine. I still think though there are certain factors that make NPs more likely to expand their scope inappropriately in the US. To flesh out my point further, in the US you have private hospitals and health networks competing with each other for patients. Yes, they also want to cut costs, but patient satisfaction is a huge aspect because if you are able to increase your patient base, you make more money. If one network brings in NPs, which adds to patient satisfaction, more personalized attention etc., they may actually bring in more patients from a rival network where they don't use NPs, thus potentially making more profit and growing their business.

In Canada however, patients aren't being fought over as much by different hospitals, the government is the only insurer and so the government is trying to cut costs but they aren't as incentivized to make patients happy. The government will only like NPs if they cut overall healthcare costs. The angle doctors need to take is to say, yes maybe you pay them less, but they don't see as many patients, ask for more specialist consults and order more blood work, ultimately, they are not cost efficient.  

 

[Redpill]

On 2/6/2022 at 9:32 PM, Edict said:

In Canada however, patients aren't being fought over as much by different hospitals, the government is the only insurer and so the government is trying to cut costs but they aren't as incentivized to make patients happy. The government will only like NPs if they cut overall healthcare costs. The angle doctors need to take is to say, yes maybe you pay them less, but they don't see as many patients, ask for more specialist consults and order more blood work, ultimately, they are not cost efficient.  

 

This is a hopelessly optimistic take. Doctors of BC has been saying this for years to the BC government, but the government doesn't believe them or doesn't care. They continue to expand NP programs for many of the reasons already described in this thread.

These decisions are made due to politics, and not because they are the most cost effective or sensible.

[guy30]

  

On 1/31/2022 at 8:53 PM, brackenferns said:

Agreed. It's also totally plausible to rework the FM curriculum within the two years to produce the kind of primary care physicians that can hit the ground running.

Now that I'm in practice, this is the curriculum I would've found to be the most useful (for solely ambulatory / outpatient primary care practice):

(Assuming family medicine clinics are half-days and intermixed with the rotations)

- 3 months of general pediatrics (mostly newborn clinic + ambulatory care; some inpatient / NICU but keep it minimal)

- 1 month of subspecialty pediatric clinics (1 week in each of: asthma / resp, developmental delay, feeding / constipation, and what selective of choice); on-call will be pediatric consults in the ED for the entire 4 months

- 2 months of general office-based gynecology / obstetrics (learn how to insert IUDs; rotation with MFM), on-call will be a mix of being overnight in L&D + doing ED consults

- 1 month of addictions / STI / HIV clinic; no call but use this block to one of those QI / social determinants of health / research things that resident directors love

- 5 months of internal medicine (I actually don't think GIM ambulatory clinics are that useful, because patients are often in the middle of their medical workup and you don't have the full context; I'd rather do disease specific clinics like HTN, DM, CHF, COPD, CKD, did I mention DM?, fatty liver / cirrhosis, IBS, hepatitis, ID / wound care...; can do some CTU but just enough so you get the in-patient context), on-call for internal medicine consults in ED

Now we are at 12 months.

- 0.5 month (2 weeks) of general surgery (add some OR time if you want surgical assist, otherwise just do ambulatory clinic so you recognize all the common pathologies; get good at lumps + bumps), on-call for gen surg so you recognize acute abdomens

- 1.5 month (6 weeks) of surgical subspecialty ambulatory clinics (1 week each in ENT, urology, ophthalmology, plastics, orthopedics, whatever selective of your choice; the takeaway is to learn 1 - the emergencies in each field, and 2 - indications / workup for common referrals), on-call for each of those specialties so you get a flavour of the emergencies in each field

- 3 months of psychiatry (get some experience with CBT; mostly outpatient clinics; do rotations in memory clinic so you know how to diagnose and manage cognitive disorders / dementias), on-call for psych

- 2 months of dermatology (yes, that long in dermatology, get really good at biopsies + rashes because they are so common), not too much derm emergencies so you do ED shifts as your call

- 1 month of emergency medicine (I would recommend have a teaching day before your first shift just to ensure you know all the ACLS / trauma protocol / procedures / etc.. before you start)

- 2 months of MSK clinics (sports med + rheumatology), on call for orthopedics during this time, learn how to cast + do joint injections

- 2 months of neurology clinics so you really know how to do a neuro exam (I'd say 2 weeks of headache clinic, 2 weeks doing something in peripheral neuro, 1 week in TIA clinic so you know the workup + general management, 1 week doing seizure so you know the meds + approach, 1 week in movement so you can recognize Parkinsonism, and 1 week doing MS so you at least know what to say when patients ask you if so-and-so symptom is MS), on call for neurology during this time, see if you can work with neurosurg too so you  see some acute intracranial stuff (again just to recognize the clinical findings so you can disposition to ED)

On-call should be a combination of consults + also being called up seeing specific clinical presentations + findings on the wards (i.e. you don't have to manage ward issues on call but at least know what clinical finding Y looks like so you won't miss it in the outpatient world). The staff you're with should facilitate this.

Also, family medicine programs be more hands-on with its trainees. I would've gotten more out of the experience if I was explicitly told, at the beginning of each rotation, that this is how you're supposed to do a consult, these are the learning objectives, and these are the cases you have to see. Being hands-off and doing the self-directed learning thing works for other specialties that are 1 - longer, and 2 - have more immersion (i.e. you live at the hospital). Two years finish fast and you need to have a program that pulls you from rotation to rotation and tells you what to learn.

And... that's it! Main thing that's missing here is palliative care but it can probably be included in the family medicine half days as home visits, or maybe on internal medicine. Same with LTC / geriatrics. Or just do the +1.

 

 

 

On 2/1/2022 at 5:54 PM, JohnGrisham said:

I like it, except its missing proper time on longitudinal FM block, and rural FM?    Truthfully, i dont think half-days alone are enough without block time on FM clinic.  But the rest of it, is spot on and would be great learning to bring into clinic. But you need clinic base of block time to learn how to manage time, run a clinic setting etc

 

Yeah that's exactly it, hence the need for a 3rd year, there's just way too much to pack in to 2 years and stuff gets missed so there's deficiencies on graduation for a good chunk of new family docs. 

 

Longitudinal half days in FM are definitely not enough and you absolutely need dedicated block time.  You can't tell me that you're going to design a 2 year family medicine residency and essentially not be taught by family physicians during the large majority of the time?

 

I think the 3rd year would be a great opportunity for residents to do dedicated enhanced skills time and develop specific areas of focus that would serve the communities they are going to practice in (ie palliative, primary care obs, EM, addictions, MSK etc.), and then also having a good chunk of dedicated time to operate as a junior FM attending basically running the show.

 

The dedicated enhanced skills/fellowship time and opportunities to operate as a junior attending are already built into several Royal College programs as a resident (ie GIM that is essentially finished in 3 years + 1 year of enhanced skills and junior attending time, EM that is really 3 years + 1 year of fellowship + 1 year of junior attending, Peds too has a similar model I believe).  I think this develops superior graduates that are more ready for independent practice with a more solid base to build their knowledge from going into practice and can better serve the communities they are going to work in whether urban or rural (ie palliative care, MSK, and pain medicine are all in demand skills in urban areas as well.  EM, Obs, and hospitalist more in rural areas but can also be urban need as well).

 

I don't know why but FM seems to always have this just 'wing-it' type of dogma that is engrained in everyone whereas the Royal College has a much more being almost too over-prepared and over-trained type of mentality to training.  I think 3 years helps grads to develop a more solid base and avoids funneling people into only office primary care or only hospital based focuses.  Tons of new grads like to locum for a while first before settling into practice and decreasing their scope of practice to only the office primary care stream could take away that flexibility from them.  It would also potentially make recruiting FM docs to rural areas more difficult since there'd be a smaller base of docs to choose from.

[regular]

It’s crazy to hear doctors quibbling about adding a third year when NPs with way less training are being paid the same to do the job with better benefits and overhead assistance.

 

[Wachaa]

5 hours ago, regular said:

It’s crazy to hear doctors quibbling about adding a third year when NPs with way less training are being paid the same to do the job with better benefits and overhead assistance.

 

Here’s a typical profile for NP wages in BC.

Yes, that is more money per patient than for a GP contract.

The $75k overhead is for smaller communities too. In Metro Vancouver it is $85k if I remember correctly. Very nice NP contracts. There's no benefits though.

The CFPC is very out of touch. They seem to think that GP graduates aren't choosing to practice longitudinal primary care because the billing system is too complex or they don't feel prepared... not addressing the real problems. New grads are happily practicing walk in, hospitalist, or ER.

[guy30]

I think it's awful how the BC government is treating family docs and the NP renumeration is ridiculous, especially adjusted for panel size and overhead in BC. 

 

But I also think that it's important to remember this is province specific and this shouldn't become a 'race to the bottom' with NP's.  We shouldn't be trying to outcompete with NP's on how little training we can have while still providing the same minimum quality of care.  It's also a false equivalency when people comment on how they got by just fine with just a 1 year of internship back in the day as well.  Medicine, and specifically family medicine, has changed a lot in the last several decades with standards of care, medical knowledge, types of medications, treatments etc. now vastly different.  Rather we need to exemplify the expert knowledge and care of family medicine as a specialty and why family physicians are the head of the primary care team.  Part of that is through bolstering the training of residents and improving our training which is what a 3 year residency provides the opportunity to do.

 

The CFPC does do advocacy for family medicine as a specialty but their main role as a college is setting standards for family medicine training.  BC family doc's poor renumeration compared to NP's is ultimately the responsibility of Doctors of BC as the negotiating body for family docs with the provincial government and the CFPC doesn't have any direct role in setting renumeration.  One factor that does factor into renumeration negotiations however is residency training length.  It won't be the only thing that helps tip the scales but that is the often quoted reason why other specialists qualify their much higher billing compared to family docs in contract negotiations.

 

I saw this chart posted online from the CFPC Outcomes of Training report that gives the reasoning for recommending a 3 year residency and found it quite telling.  In Canada, we have the shortest residency program in the developed world for family medicine but also the widest scope of practice for GP's.  We expect our FM grads to do more with less training and to just operate with the bare minimum knowledge to just get by in practice. 

No wonder why many residents don't feel clinically confident outside of office settings or aren't always able or willing to provide a wider scope of care, procedures etc.  The more we give up traditional family physician's clinical scope of practice, the more mid-levels such as NP's, PA's, and midwives creep into these areas.

[hero147]

2 hours ago, guy30 said:

I think it's awful how the BC government is treating family docs and the NP renumeration is ridiculous, especially adjusted for panel size and overhead in BC. 

 

But I also think that it's important to remember this is province specific and this shouldn't become a 'race to the bottom' with NP's.  We shouldn't be trying to outcompete with NP's on how little training we can have while still providing the same minimum quality of care.  It's also a false equivalency when people comment on how they got by just fine with just a 1 year of internship back in the day as well.  Medicine, and specifically family medicine, has changed a lot in the last several decades with standards of care, medical knowledge, types of medications, treatments etc. now vastly different.  Rather we need to exemplify the expert knowledge and care of family medicine as a specialty and why family physicians are the head of the primary care team.  Part of that is through bolstering the training of residents and improving our training which is what a 3 year residency provides the opportunity to do.

 

The CFPC does do advocacy for family medicine as a specialty but their main role as a college is setting standards for family medicine training.  BC family doc's poor renumeration compared to NP's is ultimately the responsibility of Doctors of BC as the negotiating body for family docs with the provincial government and the CFPC doesn't have any direct role in setting renumeration.  One factor that does factor into renumeration negotiations however is residency training length.  It won't be the only thing that helps tip the scales but that is the often quoted reason why other specialists qualify their much higher billing compared to family docs in contract negotiations.

I saw this chart posted online from the CFPC Outcomes of Training report that gives the reasoning for recommending a 3 year residency and found it quite telling.  In Canada, we have the shortest residency program in the developed world for family medicine but also the widest scope of practice for GP's.  We expect our FM grads to do more with less training and to just operate with the bare minimum knowledge to just get by in practice. 

No wonder why many residents don't feel clinically confident outside of office settings or aren't always able or willing to provide a wider scope of care, procedures etc.  The more we give up traditional family physician's clinical scope of practice, the more mid-levels such as NP's, PA's, and midwives creep into these areas.

I think what is more likely to happen is less people go into family medicine due to increased residency length thus bigger gaps in care leading to the government hiring more midlevels/NPs to creep even more into primary care. 

Also length of residency is not a big reason why family doctors earn less than specialists. If anything the biggest constraint is the health care budget and how much the government is willing to pay. Thus, even if all family doctors did 3 years, they would still probably be paid the same. 

[Synth1]

5 hours ago, hero147 said:

I think what is more likely to happen is less people go into family medicine due to increased residency length thus bigger gaps in care leading to the government hiring more midlevels/NPs to creep even more into primary care. 

Also length of residency is not a big reason why family doctors earn less than specialists. If anything the biggest constraint is the health care budget and how much the government is willing to pay. Thus, even if all family doctors did 3 years, they would still probably be paid the same. 

Except residency program numbers will dictate to a large extent how many go into FM. The bigger issue is how many of those go on to practice comprehensive primary care. This needs to be incentivized financially to be attractive to new grads, which provincial governments do not seem to get. 

[medigeek]

18 hours ago, guy30 said:

I think it's awful how the BC government is treating family docs and the NP renumeration is ridiculous, especially adjusted for panel size and overhead in BC. 

 

But I also think that it's important to remember this is province specific and this shouldn't become a 'race to the bottom' with NP's.  We shouldn't be trying to outcompete with NP's on how little training we can have while still providing the same minimum quality of care.  It's also a false equivalency when people comment on how they got by just fine with just a 1 year of internship back in the day as well.  Medicine, and specifically family medicine, has changed a lot in the last several decades with standards of care, medical knowledge, types of medications, treatments etc. now vastly different.  Rather we need to exemplify the expert knowledge and care of family medicine as a specialty and why family physicians are the head of the primary care team.  Part of that is through bolstering the training of residents and improving our training which is what a 3 year residency provides the opportunity to do.

 

The CFPC does do advocacy for family medicine as a specialty but their main role as a college is setting standards for family medicine training.  BC family doc's poor renumeration compared to NP's is ultimately the responsibility of Doctors of BC as the negotiating body for family docs with the provincial government and the CFPC doesn't have any direct role in setting renumeration.  One factor that does factor into renumeration negotiations however is residency training length.  It won't be the only thing that helps tip the scales but that is the often quoted reason why other specialists qualify their much higher billing compared to family docs in contract negotiations.

 

I saw this chart posted online from the CFPC Outcomes of Training report that gives the reasoning for recommending a 3 year residency and found it quite telling.  In Canada, we have the shortest residency program in the developed world for family medicine but also the widest scope of practice for GP's.  We expect our FM grads to do more with less training and to just operate with the bare minimum knowledge to just get by in practice. 

No wonder why many residents don't feel clinically confident outside of office settings or aren't always able or willing to provide a wider scope of care, procedures etc.  The more we give up traditional family physician's clinical scope of practice, the more mid-levels such as NP's, PA's, and midwives creep into these areas.

 

 

Maybe just increase some +1 options? 2 years is enough for clinic work. If you're doing major hospitalist work, then ya you need the extra training. Same with EM unless you really focused on EM in your 2 years and also in your 3rd/4th year med school. 

Procedures can be learnt in 2 years if you actually do them. How many FM residents are learning procedures in the clinic setting in their 2 years? Certainly many do tons of them. But many do almost none. It doesn't take a 3rd year to learn how to place IUDs or do joint injections or derm procedures. 

[virox_facewash]

On 3/29/2022 at 10:39 AM, Synth1 said:

Except residency program numbers will dictate to a large extent how many go into FM. The bigger issue is how many of those go on to practice comprehensive primary care. This needs to be incentivized financially to be attractive to new grads, which provincial governments do not seem to get. 

I would add that the senior leaders in FM, particularly as represented by the CCFP, seem really out of touch about why new grads are not going into comprehensive care. There's a lot of complaining about the trend towards focused practice and episodic care, while ignoring why it's happening. I've even heard older docs say that young grads should just be forced to work rurally after finishing residency, which to me feels punitive and is guaranteed to drive people away from FM. I'm not averse to the idea of some kind of extended training if it's about enhancing quality of care, but it certainly won't attract more people to family medicine and could backfire as other people have pointed out.

[virox_facewash]

On 2/7/2022 at 12:08 AM, indefatigable said:

Indeed.  I have been told by very experienced FPs that patients who are used to frequent referrals/specialized care (available large metro centres) expect that level care and are disappointed when such care is not feasible.  

Comes as no surprise, but expectations are definitely higher in large metro centres. Patients frequently turn up to the office or the ED for the sole purpose of obtaining an expedited elective referral or imaging. In my experience, patients in smaller communities (and not even just really tiny ones) are more open to being told that a certain referral isn't warranted, and are less likely to demand second-opinion referrals for chronic conditions that have already been worked up. Same goes for imaging. Expectations seem to scale with availability.

[zoxy]

1 hour ago, virox_facewash said:

I would add that the senior leaders in FM, particularly as represented by the CCFP, seem really out of touch about why new grads are not going into comprehensive care. There's a lot of complaining about the trend towards focused practice and episodic care, while ignoring why it's happening.

The supposed "leaders" think it's because graduating FM docs are unprepared. They cannot possibly imagine how the current fee codes and the overall structure of the fee for service model in Canada greatly disincentivizes comprehensive care, not to mention patients treating FM as a doormat for specialized care. Give an FM the same sort of contract that the NPs in BC have, and educate the public about the rigours of medical training in Canada, then you'll see who has better outcomes with happier patients.

Future generations of Canadian FMs are being thrown under the bus by a troika of provincial governments, senior FM "leaders", and Medical School administrators. Medicine truly eats its young.

[indefatigable]

1 hour ago, zoxy said:

The supposed "leaders" think it's because graduating FM docs are unprepared. They cannot possibly imagine how the current fee codes and the overall structure of the fee for service model in Canada greatly disincentivizes comprehensive care, not to mention patients treating FM as a doormat for specialized care. Give an FM the same sort of contract that the NPs in BC have, and educate the public about the rigours of medical training in Canada, then you'll see who has better outcomes with happier patients.

Future generations of Canadian FMs are being thrown under the bus by a troika of provincial governments, senior FM "leaders", and Medical School administrators. Medicine truly eats its young.

This ^^

Extending FP residency to 3 years will erode family medicine

NPs and PAs are already expanding into primary care. This CFPC decision is wrong headed, argues Dr. Teela Johnson.

I am concerned that the College of Family Physicians of Canada’s recent move to have family medicine residency be three years, rather than two, will harm the specialty.

Family medicine is increasingly being practiced by NPs and PAs, both groups who have magnitudes of order less training than family doctors. These groups have done an excellent job advocating for themselves vis a vis that less training is not a problem, and in response, many patients feel comfortable receiving primary care from them.

Concomitantly, patients are increasingly doing their own research, requesting referrals to specialists and seeking episodic, virtual, and convenient care that works with their schedule. The value previously placed on a continuous care relationship is being trumped by convenience considerations.

Family medicine already has a PR problem. The hidden curriculum at med school is that family medicine is the lowest status specialty, and one of the lowest paid. Adding in an extra year of training, when evidence shows that patients who have a family doctor have a mortality benefit, and at a time when the role of family doctors is being eroded through government-sanctioned increases in the of number mid-level providers, seems detrimental to the future of family medicine in Canada. If NPs and PAs are providing safe care with less training, then why has the college chosen this direction?

The issues raised in the CFPC report outlining the rationale for this change—e.g., fewer family docs providing comprehensive medicine—are remuneration related, not competence related. If family doctors were paid appropriately for all the critical work that they do daily, there would be more time to discuss with patients why a specialist referral is not needed for X issue. There would also be more family doctors. Expecting the country’s best and brightest to flock to a specialty with a high administrative burden and low pay is misguided, and a longer residency is not the solution.

In short, extending residency training at this time will further erode the human resources crisis in family medicine and contribute to patients being treated by providers with significantly less training.

Dr. Teela Johnson is a hospitalist at Unity Health in Toronto, and she holds a faculty appointment at the University of Toronto in the Department of family medicine. Her views here are her own. 

source: https://www.canadianhealthcarenetwork.ca/extending-fp-residency-3-years-will-erode-family-medicine?utm_source=omeda&utm_medium=email&utm_campaign=NL_CHN_Physician_REG&utm_keyword=&oly_enc_id=6234G2816812E5Z

 

[1D7]

This thread is a bit of a pityparty regarding FM. Reality is that in FM is paid close to what the average GSx is paid while having 3 fewer years of training and much less overnight work. If you compare this to a subspecialist interventional neuroradiologist, FM is paid just under half of a NIR while having 6 fewer years of training and a incomparable difference in the amount of overnight work (1/2 to 1/3 stroke call). This is ignoring the fact that some specialists are doing additional training to find work and have much higher medmal risk. I don't know what exact number is fair, but FM pay per hour worked is at least average amongst specialties, and is especially good when factoring in overnight work & training length.

Ultimately, I agree that 2 years is enough, mainly because it is enough to feel comfortable with outpatient FM clinics.

[zoxy]

On 3/30/2022 at 1:10 PM, 1D7 said:

 Reality is that in FM is paid close to what the average GSx is paid while having 3 fewer years of training and much less overnight work. If you compare this to a subspecialist interventional neuroradiologist, FM is paid just under half of a NIR while having 6 fewer years of training and a incomparable difference in the amount of overnight work (1/2 to 1/3 stroke call). I don't know what exact number is fair, but FM pay per hour worked is at least average amongst specialties, and is especially good when factoring in overnight work & training length.

I think FM making the same as GenSx is only the case in Ontario, and only those FMs in an FHO not in the FFS model. Generalizing this situation to other provinces such as Quebec, BC, and the Maritimes isn't entirely accurate.

And while FM is not so bad now, the new training paradigm will simultaneously increase length of training, detracting from one of the main benefits of FM, while increasing expectations of FM.

Also there is no indication that this expectation of increasing scope and the management of more medically complex patients who require more time consuming visits will be matched by increased payments and changes in billing codes.

So the sum of these changes will be longer FM training, a greater burden of work, with no corresponding increase in fees.

 

[futureGP]

2 years or 3 years

lazy ones will be lazy still

you won’t change quality of FMs with 2 or 3 years of residency. 
 

More med students will gun for specialty residencies, more FM spots will go unfilled, less FPs, less lobbying power, more midlevels.

Pls CFPC, don’t shoot yourself in the foot. 

Keep 2 years and make training more relevant for practise. Also why not make the CFPC exam more relevant.

 

there’s no point comparing FM training across different countries that have completely different healthcare systems.

US FM is 3 year in training but also healthcare is a lot more profit driven - means you need time to learn profit-generating skills for it to be worthwhile.

UK GP training is long because their GPs need to do more as part of NHS design which regionalizes specialty care.

 

Canadian FMs need to adapt to the canadian healthcare system. In the urban areas where access to specialist care is easy and patients also demand a specialist for every little medical issue, FMs don’t need to do 3 year training to be the ‘comprehensive general practitioner’ that the idealistic CFPC bureaucrats wish who they were.

[shikimate]

FM makes the same as GSx in Ontario? What numbers are we talking about here? Like the GSx I know (not in ON) makes 400-600K gross. I am pretty sure the average FM in the same city don't bill that much without doing "extra" such as inpatient work etc.

 

[guy30]

On 3/29/2022 at 2:52 AM, hero147 said:

I think what is more likely to happen is less people go into family medicine due to increased residency length thus bigger gaps in care leading to the government hiring more midlevels/NPs to creep even more into primary care. 

Also length of residency is not a big reason why family doctors earn less than specialists. If anything the biggest constraint is the health care budget and how much the government is willing to pay. Thus, even if all family doctors did 3 years, they would still probably be paid the same. 

With GIM effectively being 5 years now (and other specialties often requiring multiple years of additional fellowship just to get a job), I don't think less people will go into FM if it becomes 3 years now.  Canada has a dearth of residency positions, until we get into a position where there is an oversupply, you won't have less people going into family medicine.  What we should be doing is championing family medicine as a specialty and making the actual practice of family medicine appealing to medical students.  A lot more goes into it than just simply residency length but things like scope of practice, ability to tailor one's practice, agency and control over your time and care (ie work/life balance), relationships with patients, and of course renumeration, etc.

 

Everyone keeps saying that 2 years is enough for office based practice but the thing is, many family doc's don't do just office based practice nowadays because it's a recipe for burnout and their communities need family doc's to do more broad based care.  For example, many family doc's do a few days of clinic each week with something else added on such as LTC, or women's health clinic, sexual health clinic, addictions, MSK, mental health, emerg, derm, cosmetics, hospital care etc. etc. the list goes on.  Brackenferns came up with an 'ideal' type of dream 2 year residency above and there was barely enough time to fit all the exposure required for the modern family doc grad to go through and he/she included zero family medicine block time during that.  Essentially an entire FM residency exposed to the different areas taught by other specialists with no dedicated time being taught by family docs!  That's just shows you 2 years is not enough time.

 

Residency length is not the reason why family doc's in many provinces are poorly renumerated.  However, residency length is a part of the reason for large income disparities between specialists and family doc's.  Many provincial medical associations have gone through income disparity analysis exercises to try to even out income between family doc's and specialists and training time always goes into the calculation on why there's lower renumeration relative to specialists.

 

Also again, the CFPC is NOT responsible for family doc renumeration in Canada.  This is a negotiating responsibility of provincial medical associations, CFPC set's standards of training for family doc's in Canada.

[medigeek]

19 hours ago, futureGP said:

2 years or 3 years

lazy ones will be lazy still

you won’t change quality of FMs with 2 or 3 years of residency. 
 

More med students will gun for specialty residencies, more FM spots will go unfilled, less FPs, less lobbying power, more midlevels.

Pls CFPC, don’t shoot yourself in the foot. 

Keep 2 years and make training more relevant for practise. Also why not make the CFPC exam more relevant.

 

there’s no point comparing FM training across different countries that have completely different healthcare systems.

US FM is 3 year in training but also healthcare is a lot more profit driven - means you need time to learn profit-generating skills for it to be worthwhile.

UK GP training is long because their GPs need to do more as part of NHS design which regionalizes specialty care.

 

Canadian FMs need to adapt to the canadian healthcare system. In the urban areas where access to specialist care is easy and patients also demand a specialist for every little medical issue, FMs don’t need to do 3 year training to be the ‘comprehensive general practitioner’ that the idealistic CFPC bureaucrats wish who they were.

UK GPs aren't doing more than Canada. Canadian and American FM docs have some of the widest scope of practices globally for generalists. In Europe, many GPs/FM docs aren't even ordering advanced imaging without referrals. 

8 hours ago, shikimate said:

FM makes the same as GSx in Ontario? What numbers are we talking about here? Like the GSx I know (not in ON) makes 400-600K gross. I am pretty sure the average FM in the same city don't bill that much without doing "extra" such as inpatient work etc.

 

Yeah but how much is general surgery working to make 500k? 

 

4 hours ago, guy30 said:

With GIM effectively being 5 years now (and other specialties often requiring multiple years of additional fellowship just to get a job), I don't think less people will go into FM if it becomes 3 years now.  Canada has a dearth of residency positions, until we get into a position where there is an oversupply, you won't have less people going into family medicine.  What we should be doing is championing family medicine as a specialty and making the actual practice of family medicine appealing to medical students.  A lot more goes into it than just simply residency length but things like scope of practice, ability to tailor one's practice, agency and control over your time and care (ie work/life balance), relationships with patients, and of course renumeration, etc.

 

Everyone keeps saying that 2 years is enough for office based practice but the thing is, many family doc's don't do just office based practice nowadays because it's a recipe for burnout and their communities need family doc's to do more broad based care.  For example, many family doc's do a few days of clinic each week with something else added on such as LTC, or women's health clinic, sexual health clinic, addictions, MSK, mental health, emerg, derm, cosmetics, hospital care etc. etc. the list goes on.  Brackenferns came up with an 'ideal' type of dream 2 year residency above and there was barely enough time to fit all the exposure required for the modern family doc grad to go through and he/she included zero family medicine block time during that.  Essentially an entire FM residency exposed to the different areas taught by other specialists with no dedicated time being taught by family docs!  That's just shows you 2 years is not enough time.

 

Residency length is not the reason why family doc's in many provinces are poorly renumerated.  However, residency length is a part of the reason for large income disparities between specialists and family doc's.  Many provincial medical associations have gone through income disparity analysis exercises to try to even out income between family doc's and specialists and training time always goes into the calculation on why there's lower renumeration relative to specialists.

 

Also again, the CFPC is NOT responsible for family doc renumeration in Canada.  This is a negotiating responsibility of provincial medical associations, CFPC set's standards of training for family doc's in Canada.

you really just need the +1 opportunities for things that actually need them like inpatient or emerg work. Also, 2 years in downtown Toronto is not the same as 2 years in a good busy community where everyone is interested in teaching. 

[Redpill]

10 hours ago, guy30 said:

Also again, the CFPC is NOT responsible for family doc renumeration in Canada.  This is a negotiating responsibility of provincial medical associations, CFPC set's standards of training for family doc's in Canada.

But that doesn't mean they can make their decisions in a vacuum. We all live in the same world, the CFPC can't plug their fingers in their ears to legitimate concerns around lack of increased remuneration for their proposed increased training time, just because it is not their responsibility.

[GH0ST]

Another problem in the mix... (I know most of you guys probably don't care)

While I don't see a particular problem with the premise of increasing competency... 3 year FM will significantly affect PHPM+FM programs. The PHPM program is based on a 2 yr FM program or 1 year clinical year. By making this 3 years... it will force the specialty to either extend PHPM to a 6 year residency or in the worst case scenario, drop FM altogether. 

Imagine potentially extending PHPM without being able to do more work to build public health competency but because of another program outside of one's control...

Having the clinical background is really important particularly in communicable disease control public health specialists since there's arguably more clinical decision making done, just on a different scale. Losing touch with that or having the lack of exposure without FM will definitely impact PHPM. 

*cue all the "PHPM isn't medicine/doctor comments - please keep that opinion to yourself*

- G