Family Med 3 years?

[shikimate]

Aren't there PHPM programs without FM already? Looks like they're already phasing out FM...

We all know solid clinical background is important for every specialty, even ones like PHPM, pathology, radiology etc. But looks like after the got rid of internship year, and with new CBD, it's less and less about generalist skills and more and more on specialist skills...

[HoopDreams]

10 minutes ago, GH0ST said:

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

In Québec, the job market for PHPM graduates offers position where PH practice is full time, making the value of the FM training somewhat less applicable. As such, in the province, only McGill offers the double certification option (FM+PHPM) but all graduates end up not using that FM certification.

In the context of a 3 years FM training, with the increasing scope of knowledge in PHPM, I believe that two possibilities exist :

- PHPM continues to offer double-certification, remains 5 years, 3 years of FM, 1 year of accelerated MPH, 1 year of PHPM rotations
- PHPM stops the double-certification, remains 5 years, 1 year FM, 2 year of masters, 2 years of PHPM rotations.

 

In any case, 2 years of FM training to be an independent clinician ready to work in the ward, ED, caseroom, is just too short in my opinion.

 

 PHPM programs will not extend their training but rather stop offering the double-certification.

[GH0ST]

5 minutes ago, shikimate said:

Aren't there PHPM programs without FM already? Looks like they're already phasing out FM...

We all know solid clinical background is important for every specialty, even ones like PHPM, pathology, radiology etc. But looks like after the got rid of internship year, and with new CBD, it's less and less about generalist skills and more and more on specialist skills...

The vast majority of PHPM programs include FM. The vast majority of residents do FM. A small minority forgo FM training to do more PHPM training. Some of the programs however do have a PHPM only route vs PHPM+FM. To my knowledge, only Saskatchewan has PHPM only. 

- G 

[GH0ST]

2 minutes ago, HoopDreams said:

In Québec, the job market for PHPM graduates offers position where PH practice is full time, making the value of the FM training somewhat less applicable. As such, in the province, only McGill offers the double certification option (FM+PHPM) but all graduates end up not using that FM certification.

In the context of a 3 years FM training, with the increasing scope of knowledge in PHPM, I believe that two possibilities exist :

- PHPM continues to offer double-certification, remains 5 years, 3 years of FM, 1 year of accelerated MPH, 1 year of PHPM rotations
- PHPM stops the double-certification, remains 5 years, 1 year FM, 2 year of masters, 2 years of PHPM rotations.

 

In any case, 2 years of FM training to be an independent clinician ready to work in the ward, ED, caseroom, is just too short in my opinion.

 

 PHPM programs will not extend their training but rather stop offering the double-certification.

That last sentence is what I'm worried about. 

I will say as someone who did their MPH and am going through core PHPM rotations... one year isn't enough. Heck, even after two years it's hard to manage building those core competencies. 

Most places will give you the one year but after that you'll also need to find longitudinal experiences to keep graduation on time. For placements you can replace that with a core PHPM rotation so that helps with the timing issue. 

- G

[guy30]

17 hours ago, GH0ST said:

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

Well in the same vain of talking about extending FM from 2 years to 3 years to increase competency and clinical confidence outside of purely office based primary care, has anyone thought of how PHPM maybe doesn't really need to be a 5 year program?  Along with a lot of Royal College programs that probably don't really need to be as long as they currently are (ie PHPM 5 years, GIM 5 years essentially if you want a job, General Pediatrics 4 years, EM 5 years), yet I don't really hear people out there arguing to shorten these programs for some reason.  These programs are all generalist type programs somewhat similar to FM in their broad scope of practice and knowledge.

 

Imagine the impact shortening PHPM to 2-3 years, GIM to 2-3 years, General Pediatrics to 2 years (if FM can do it in 2 years then why not), and EM to 2-3 years would have on increasing the number of these types of physicians in the next few years on our physician work force?  We can have everyone just learn on the job and figure it out in practice just like FM after they've reached bare bones competency.  Why don't we shorten each of these Royal College programs by a year each year and double our new physician work force for the next couple years to solve our workforce shortages, brilliant!   Of course I'm saying all this in jest because short term thinking doesn't take a good long term strategic outlook of each specialty into account, the same as why FM as it's own specialty needs a longer term focus to be taken into account for the growth of the specialty. 

 

Just as increasing FM from 2 to 3 years has a short term impact on the family physician work force and can be mitigated by a multitude of ways including the gradual transitioning of programs across the country, offering all residents 3 years of funding by evaluating residents purely on a competency based model that allows them to finish earlier if so desired etc., this has long term strategic impacts on the growth of FM as a specialty and developing the core competencies of graduating FM doc's over the long term preventing more mid-level creep (prime examples include midwives for primary care obstetrics, NP's for addictions medicine, hospitalist etc.)

 

I imagine if we offered all FM residents across the country 3 years worth of funding, the majority of residents would do at least more than 2 years of residency to increase their skill set and develop skills that fit their communities.  I think that it would be a minority of residents that would actually just leave after exactly 2 years (and that's if they are even able to achieve the full slate of the new CPA's/EPA's the CFPC has developed for family medicine in this report within the existing 2 year time frame to graduate).  FM is hugely broad in scope and the competencies required take longer than 2 years to be truly confident and competent in, otherwise new FM grads will keep their scopes of practice small and you incentivize the 'referologist' or the burned out family doc that only does office practice without any variety in practice or other skill sets outside of primary care office work.

[virox_facewash]

 (deleted)

[JohnGrisham]

7 hours ago, guy30 said:

I imagine if we offered all FM residents across the country 3 years worth of funding, the majority of residents would do at least more than 2 years of residency to increase their skill set and develop skills that fit their communities. 

This isn't what is being offered though. What is being said is "you all do 3 years, and we will tell you what rotations you will be doing".

If they wanted to, they could offer much more +1s and training funding right now, but they don't want to do it without strings attached. Its clear as day. They want to have more FM training labour, and sequester more.

[medigeek]

33 minutes ago, JohnGrisham said:

This isn't what is being offered though. What is being said is "you all do 3 years, and we will tell you what rotations you will be doing".

If they wanted to, they could offer much more +1s and training funding right now, but they don't want to do it without strings attached. Its clear as day. They want to have more FM training labour, and sequester more.

And that's the issue. Doing a 3rd year where you're just doing a lot of clinic is not useful at all. Outpatient work has a pretty low point of diminishing returns in the context of residency. Yes there is a lot to learn but a lot of that comes with years of experience and independent motivation to learn. 

I just don't see how they add a 3rd year and make it mostly non-clinic based. And even then, what will the emphasis be on? It would only make sense if it's structured towards one's interests.

Also comparing the USA system doesn't make as much sense. PGY1 in USA has minimal outpatient time and is very hospital heavy, then by PGY3 you're more outpatient than anything else. That's a big difference. 

[guy30]

2 hours ago, JohnGrisham said:

This isn't what is being offered though. What is being said is "you all do 3 years, and we will tell you what rotations you will be doing".

If they wanted to, they could offer much more +1s and training funding right now, but they don't want to do it without strings attached. Its clear as day. They want to have more FM training labour, and sequester more.

Where are you getting that though?  The CFPC Outcomes of Training Report is here:

https://www.cfpc.ca/CFPC/media/Resources/Education/AFM-OTP-Report.pdf

 

It recommends pursing a standard training length of 3 years and developing a taskforce with key stakeholders to develop an implementation plan including testing different training models.  Another recommendation of the report is to adopt the use of CPA's (ie EPA's) with core competencies resident's need to achieve prior to graduation.

 

This is clearly something that is still in early development and hasn't been set in stone yet.  It offers a huge opportunity to shape how we want residency training for FM grads to look like.

 

Residency funding is controlled by provincial governments, not the CFPC.  The CFPC can't just offer more training funding or +1's, only accredit programs that already have funding.  If all FM grads are required to have 3 years of funding to become family doc's, then provincial governments need to provide that funding to generate family doc's since that's the new training requirement for all grads now.  A much more effective way of getting more funding then trying to get governments to funding +1 programs here and there.

[hero147]

Is it just me or is anybody else finding a family medicine residency more and more unappealing? 3 years and the addition of CPAs/EPAs? This is coming from someone in a specialty but had considered family medicine for the majority of my medical school career. 

[guy30]

27 minutes ago, hero147 said:

Is it just me or is anybody else finding a family medicine residency more and more unappealing? 3 years and the addition of CPAs/EPAs? This is coming from someone in a specialty but had considered family medicine for the majority of my medical school career. 

Love it or hate it, competency based education is the big trend in medical education nowadays and is not isolated to the CFPC... 

[hero147]

2 minutes ago, guy30 said:

Love it or hate it, competency based education is the big trend in medical education nowadays and is not isolated to the CFPC... 

And yet it is almost universally hated amongst all residents in most programs. It also doesn't help that the royal college implemented this crap without robust data on outcomes. Of course implementing a third year or changing the system is easy when it doesn't directly affect the people making the decisions. Are all existing family doctors going to go back for this third year of training? There's definitely a lot of family doctors (and specialist doctors!) that I would trust less than most residents graduating. 

In the spirit of competency based education, residents and their respective preceptors should be able  to discuss a resident is ready to practice independently which does not involve covering all fmaily medicine residents with an extra year willy nilly. Feeling unsure about hospitalist medicine? Maybe apply to do an electie on the wards for 1-2 months after residency. 

I also think somethign has to give. Medicine is growing an exponential rate. You can't possibly learn everything. Are family doctors going to be inresidency for 20 years in 2050? Conversations need to be started about trimming some of the fat in the medical curriculum. God I hope theyre not still teaching the Kreb cycle or Whispering pectoriloquy in medical school 

[innocentius]

.

[guy30]

2 hours ago, hero147 said:

Is it just me or is anybody else finding a family medicine residency more and more unappealing? 

What's the argument trying to be made here though?  That family medicine residency is more unappealing compared to Royal College residencies because they're moving to a CPA/EPA type system that the Royal College is also already moving towards anyways?  Or because FM residency is moving from 2 years to 3 years despite Royal College residencies also constantly increasing their training length and number of fellowships you need to obtain so that you need to be a PGY 6, 7, 8 etc. to practice?  Where's the same level of uproar when the Royal College does this?  Why the double standard for FM?

 

1 hour ago, hero147 said:

Are all existing family doctors going to go back for this third year of training? There's definitely a lot of family doctors (and specialist doctors!) that I would trust less than most residents graduating. 

There's no need for this, it's call grandfathering and happens all the time in medicine and other fields of work around the world when a new credential or model of training is rolled out.  Using this logic, we would never progress or change anything in training or credentialling if we required every single person prior to a new training model to go back and enter training again.

 

1 hour ago, hero147 said:

In the spirit of competency based education, residents and their respective preceptors should be able  to discuss a resident is ready to practice independently which does not involve covering all fmaily medicine residents with an extra year willy nilly. Feeling unsure about hospitalist medicine? Maybe apply to do an electie on the wards for 1-2 months after residency.  

This is already what happens as FM residency has technically been doing competency based education with the Triple C Competency based model since around 2011 before the Royal College even started moving towards it in recent years.  Not the best system but your main preceptor gathers field notes on different FM competency areas, evaluates you on readiness to practice and discusses with you on a regular basis when you are ready for independent practice during your PGY2 year (basically check's a box that goes to the university when you're ready for independent practice).  CPA's would just be an evolution of the existing model to more specific core competency areas. 

 

What isn't currently in place for both CFPC and Royal College competency based programs is the ability to take away the residency time requirement and just finish early if you've hit the ready for independent practice milestone after achieving competency in all the required areas.  FM residents rarely, if ever, hit that competency milestone much earlier than the end of PGY2 but there's nothing to say in a theoretical 3 year FM program we can't move to a true only competency based model and have residents finish earlier if they've met their core competencies and hit the ready for independent practice milestone.  I'm sure programs would also love having funding cycle back into their programs as well for people who finish earlier (and incentivizes them to do so).  The recommendation now is for the standard to be 3 years which allows funding for this time period from provincial governments but that doesn't have to mean the evaluation model can't change to recognize residents that finish quicker. 

 

Like I said before, I really doubt the majority of residents would decline additional training time in an area they are interested in that serves their communities if it was offered to them or even just more time to better learn how to lead and manage an office based practice and a multi-disciplinary primary care team.  Additional training time is already what happens in Royal College programs with built in funding and fellowship time within their existing core residency funding and years.  Your comment about just applying to do 1-2 months of elective time on the wards if you're unsure about hospital medicine is easier said than done once you've entered into independent practice.  There is no dedicated funding across the country to just be able to do this, there is no structure for education or framework for evaluation, it is difficult to prove competency, and many people wouldn't go out of their way to willingly give up 1-2 months (if not longer) of work so uptake would be poor unless it was part of a residency program.

 

I can also see where the CFPC has a particular interest in proving core competency to people with CPA's because family doc's competency and scope of practice has been questioned in the past including from provincial regulatory college's.  Case in point, in 2018 the CPSO attempted to make it so that family doc's without additional training/certification in EM were NOT allowed to practice independently in rural ER's as they were not deemed to be competent and needed supervision in order to do so.  There was huge push back from the OCFP, SRPC, and CFPC on the generalist scope of practice and this was eventually reversed but we came very close to our largest populated province not allowing family doc's to practice EM in rural ER's when this is really supposed to be a core competency for FM in Canada.  This would have effectively collapsed rural emergency care in Ontario without family doc's manning rural ER's (many of which are  fresh grad locums from urban FM programs).

 

https://enews.rccbc.ca/2018/06/25/cfpc-cpso-amend-document-after-rural-physicians-input/ 

 

Who's to say in the future people also won't start questioning the ability for family doc's to do primary care obstetrics in Canada or hospitalist medicine for example?  In many other developed countries (see the table I posted previously), family doc's have already lost the ability to deliver babies in hospitals and it is midwives that are the primary provider doing the deliveries with OB as backup if things go sideways (Australia and NZ are prime examples of this model of care).  Or in many comparable developed countries, family doc's have also lost the ability to practice hospitalist medicine as well.  So CPA's can be a tool to help prove competency, force university programs to actually train FM resident's better with increased exposure, procedural skills etc to show competency, and bolster the public's confidence in FM grad's competency as true specialists in family medicine.  All this is very difficult to do in a 2 year program which is why 3 years of funding is crucial for more fulsome training and demonstration of competency for graduating family doc's.

[hero147]

29 minutes ago, guy30 said:

What's the argument trying to be made here though?  That family medicine residency is more unappealing compared to Royal College residencies because they're moving to a CPA/EPA type system that the Royal College is also already moving towards anyways?  Or because FM residency is moving from 2 years to 3 years despite Royal College residencies also constantly increasing their training length and number of fellowships you need to obtain so that you need to be a PGY 6, 7, 8 etc. to practice?  Where's the same level of uproar when the Royal College does this?  Why the double standard for FM?

 

There's no need for this, it's call grandfathering and happens all the time in medicine and other fields of work around the world when a new credential or model of training is rolled out.  Using this logic, we would never progress or change anything in training or credentialling if we required every single person prior to a new training model to go back and enter training again.

 

This is already what happens as FM residency has technically been doing competency based education with the Triple C Competency based model since around 2011 before the Royal College even started moving towards it in recent years.  Not the best system but your main preceptor gathers field notes on different FM competency areas, evaluates you on readiness to practice and discusses with you on a regular basis when you are ready for independent practice during your PGY2 year (basically check's a box that goes to the university when you're ready for independent practice).  CPA's would just be an evolution of the existing model to more specific core competency areas. 

 

What isn't currently in place for both CFPC and Royal College competency based programs is the ability to take away the residency time requirement and just finish early if you've hit the ready for independent practice milestone after achieving competency in all the required areas.  FM residents rarely, if ever, hit that competency milestone much earlier than the end of PGY2 but there's nothing to say in a theoretical 3 year FM program we can't move to a true only competency based model and have residents finish earlier if they've met their core competencies and hit the ready for independent practice milestone.  I'm sure programs would also love having funding cycle back into their programs as well for people who finish earlier (and incentivizes them to do so).  The recommendation now is for the standard to be 3 years which allows funding for this time period from provincial governments but that doesn't have to mean the evaluation model can't change to recognize residents that finish quicker. 

 

Like I said before, I really doubt the majority of residents would decline additional training time in an area they are interested in that serves their communities if it was offered to them or even just more time to better learn how to lead and manage an office based practice and a multi-disciplinary primary care team.  Additional training time is already what happens in Royal College programs with built in funding and fellowship time within their existing core residency funding and years.  Your comment about just applying to do 1-2 months of elective time on the wards if you're unsure about hospital medicine is easier said than done once you've entered into independent practice.  There is no dedicated funding across the country to just be able to do this, there is no structure for education or framework for evaluation, it is difficult to prove competency, and many people wouldn't go out of their way to willingly give up 1-2 months (if not longer) of work so uptake would be poor unless it was part of a residency program.

 

I can also see where the CFPC has a particular interest in proving core competency to people with CPA's because family doc's competency and scope of practice has been questioned in the past including from provincial regulatory college's.  Case in point, in 2018 the CPSO attempted to make it so that family doc's without additional training/certification in EM were NOT allowed to practice independently in rural ER's as they were not deemed to be competent and needed supervision in order to do so.  There was huge push back from the OCFP, SRPC, and CFPC on the generalist scope of practice and this was eventually reversed but we came very close to our largest populated province not allowing family doc's to practice EM in rural ER's when this is really supposed to be a core competency for FM in Canada.  This would have effectively collapsed rural emergency care in Ontario without family doc's manning rural ER's (many of which are  fresh grad locums from urban FM programs).

 

https://enews.rccbc.ca/2018/06/25/cfpc-cpso-amend-document-after-rural-physicians-input/ 

 

Who's to say in the future people also won't start questioning the ability for family doc's to do primary care obstetrics in Canada or hospitalist medicine for example?  In many other developed countries (see the table I posted previously), family doc's have already lost the ability to deliver babies in hospitals and it is midwives that are the primary provider doing the deliveries with OB as backup if things go sideways (Australia and NZ are prime examples of this model of care).  Or in many comparable developed countries, family doc's have also lost the ability to practice hospitalist medicine as well.  So CPA's can be a tool to help prove competency, force university programs to actually train FM resident's better with increased exposure, procedural skills etc to show competency, and bolster the public's confidence in FM grad's competency as true specialists in family medicine.  All this is very difficult to do in a 2 year program which is why 3 years of funding is crucial for more fulsome training and demonstration of competency for graduating family doc's.

My argument is most of these people making decisions aren't residents. They're either established family doctors or new family doctors with no skin in the game. They should survey existing final year medical students and see whether or not a third year of family medicine is popular or final year residents to see if they're willing to do an extra year. Also, it's a bit disingenous to say the royal college has increased training times. The PGY 7/8/9s are fellowships for the most part. You still receive your FRCPC at the end of 5/6 years. You may need a fellowship for your job sure, but you're still credentialed. How is anybody suppose to argue against the job market? People have argued for reducing residency spots in certain specialties due to the job market. Also there comes a certain point where you realize you're pwoerless as a resident. Eveeryone hated EPAs and CBD coming to FRCPC residencies. After 2 years of constant complaints from my program, nothing has changed and most people sort of just accept it. And unsurprisingly its not just my program and not just my school. 

How many people do you know who finished early in royal college specialties through CBD? I know of one program that tried it for a couple years before reverting back to graduating their residents in the standard 5 years. HEck, my program and most of the programs I am aware of have a stipulation that you're still required to put in your 2 or 5 years to finish residency. Also maybe we don't know the same residents but I do think a significant portion would mind an extra year of residency. Do you have solid data to back up the statement that most family medicine residents wouldn't mind an additional year of residency? You should also let them know that the money they lose is after they've ramp up their practice compounded by 30 years of compound interest. Of course this is all conjecture and it'd be nice to get some feedback from family medicine residents on the forum. Also do programs really have an interest in graduating their residents early? It must be nice to having what used to be fully trained doctors billing under me as PGY-3s. I don't know about you, but I wouldn't have an incentive to graduating residents early if they were making me and the hospital money. 

It was pure sarcasm to retrain the family doctors out there. But it goes to show the people voting for a third year have no skin in the game. Do all family doctors have to be able to know how to deliver babies for the CFPC to be happy? Even if its a skillt hat a family doctor who just wants to do office based medicine would never want to touch? The other question is, would you rather a family doctor delivery your baby when they do it once a month or a midwife or an ob/gyn who does it day in and day out? Family medicine is great at what it does, but stretch it too far and you may run into the situation where family doctors suck at other portions of their practices because the volume just ain't there. 

[rmorelan]

3 hours ago, hero147 said:

My argument is most of these people making decisions aren't residents. They're either established family doctors or new family doctors with no skin in the game. They should survey existing final year medical students and see whether or not a third year of family medicine is popular or final year residents to see if they're willing to do an extra year. Also, it's a bit disingenous to say the royal college has increased training times. The PGY 7/8/9s are fellowships for the most part. You still receive your FRCPC at the end of 5/6 years. You may need a fellowship for your job sure, but you're still credentialed. How is anybody suppose to argue against the job market? People have argued for reducing residency spots in certain specialties due to the job market. Also there comes a certain point where you realize you're pwoerless as a resident. Eveeryone hated EPAs and CBD coming to FRCPC residencies. After 2 years of constant complaints from my program, nothing has changed and most people sort of just accept it. And unsurprisingly its not just my program and not just my school. 

How many people do you know who finished early in royal college specialties through CBD? I know of one program that tried it for a couple years before reverting back to graduating their residents in the standard 5 years. HEck, my program and most of the programs I am aware of have a stipulation that you're still required to put in your 2 or 5 years to finish residency. Also maybe we don't know the same residents but I do think a significant portion would mind an extra year of residency. Do you have solid data to back up the statement that most family medicine residents wouldn't mind an additional year of residency? You should also let them know that the money they lose is after they've ramp up their practice compounded by 30 years of compound interest. Of course this is all conjecture and it'd be nice to get some feedback from family medicine residents on the forum. Also do programs really have an interest in graduating their residents early? It must be nice to having what used to be fully trained doctors billing under me as PGY-3s. I don't know about you, but I wouldn't have an incentive to graduating residents early if they were making me and the hospital money. 

It was pure sarcasm to retrain the family doctors out there. But it goes to show the people voting for a third year have no skin in the game. Do all family doctors have to be able to know how to deliver babies for the CFPC to be happy? Even if its a skillt hat a family doctor who just wants to do office based medicine would never want to touch? The other question is, would you rather a family doctor delivery your baby when they do it once a month or a midwife or an ob/gyn who does it day in and day out? Family medicine is great at what it does, but stretch it too far and you may run into the situation where family doctors suck at other portions of their practices because the volume just ain't there. 

you know I asked specifically if you could graduate early with competency by design approaches - let's say for instance you are IMG who is actually a fully practising doctor in your home country - we had that in radiology in fact in my residency program. They automatically know almost everything already (they were super annoying in rounds ha as they always made you feel like a moron for about 4 years until you at last caught up to them) - and unlike some other fields where there may be different approaches, in my case radiology is still mostly the same everywhere - it isn't like X rays, US, or CTs are somehow different - although we may have additional access to some modalities over some other places. They could in theory demonstrate competency very quickly - easily a year or two and then boom be gone. Many fields in medicine would be similar. 

But no ha - I was told by the college that they won't let that happen - and it was a real concern of the programs originally that it would work that way. They still NEED that person for clinical service as these are never just training programs, they are also a job - so you cannot have the chaos of people leaving at random points. Imagine the response of a program director if you could leave early- as directly you would likely end up NOT accepting super high level people into the program in many cases as you are afraid they will finish quickly and leave making it hellish on the remaining people stuck doing all the extra call and in turn your life more annoying. It would be an insane situation of the likely best candidates not be accepted - as if CARMS wasn't complex enough as it is. 

Programs will let you spend what would amount to as a fellowship within your training period if you show mastery of the required competencies, which can be quite useful but not as good as just letting the person immediately go off to fellowships and so on. We still don't really have a good way of recording that something like that actually happened - and if we did it would still be dangerous - imagine surgery fields with a tight job market - you give another way for someone to say they are so good they finished early and did fellowship level work after and things just got even more stressful. This is particular a problem as the very core concept of competency by design is that equally good people learn at different rates and it is stupid to think someone is better or worse just because they reach the end point faster or later - the real question is whether they can reach the end point at all, and if so they are all effectively equal. This is still a radical thought in medicine but is a core pillar of these newer curriculum designs. 

Only point I will add about the fellowship - if you are credentialed but you cannot actually work without a fellowship then it is as if you are not credentialed at all. Same situation like graduating medical school. Congrats you are a doctor! - you still cannot do anything with that clinically without the residency so for most how useful is that in isolation. Wasn't always like the current situation in the past when there was a very rapid route to be a GP post med school. Point is the college could have figured out potentially ways that people wouldn't need a fellowship to say actually work - but they didn't or perhaps even couldn't. Just because they didn't directly increase the training time doesn't mean they are blameless in the overall process that requires a fellowship to be hired (for instance there is a lot of arguments that the majority of the first year in many programs is kind of pointless from a training point of view and the college could have worked towards revising it. There are endless arguments that the older LMCC exams were completely pointless as well but they also took up time that could be spent on other things, and they didn't directly do anything about that either. They could have worked at being more efficient during the training, and when fields get too bloated to be covered consider breaking them up - like say in radiology where interventional radiology and diagnostic radiology are separating in many places into different residencies) 

and there has to be some kind of a balance here - residents need some actual input into the system but by the same time it seems unlikely that med student graduating would truly know what is actually involved training wise to be an effective doctor in a particular area (I mean I sure as hell didn't when I started radiology - for me to say it should take 4 or 5 or 6 years would be a best a pure guess - building curriculums is really really hard work). They real question is over time is if a field is getting progressively more complex and harder and harder to cover properly in a set period of time then what do you do? 

 

 

Edited April 3, 2022 by rmorelan

[shikimate]

This is what they want with CBD: you do your royal college in 4th year, then in your 5th year, even though you are full certified, you still have to do "transition to practice", basically means you do the full workload of a staff, but take a PGY5 salary. So you do 400K worth of work, and get paid 80K, while the program/medical establishment pockets a surplus of 320K, capitalism at its best! 

You know they already love fellows so much because of the point I made above. They like it so much they can't wait until you're done PGY5 to start profiting off you, so why not do it in PGY4?

Like Rob said above, if they're so keen on assessing capabilities of residents with CBD, then shouldn't an IMG who's like an expert already be able to finish their residency in like 6 months? NO, what they want is a way to EXTEND residency. With the old system, you do your time, and at least they'll let you write your exam and finish. But with these EPAs, they could find a million excuses to delay your residency until you somehow accomplish these EPAs. In the meantime, someone is drinking champagne with those 320K surpluses. 

[hero147]

The idea of CBD is great but its terribly implemented. 

Honestly, I think fellowships should be done only when your job requires them. If not, its just wasted time. I know a lot of people who have done fellowships in x,y, and z just to work in the community and use nothing they learned in fellowship. It's honestly starting to become a running joke. And in reponse to @guy30, just because there isn't outrage at the royal college level about fellowships and increasing training times, doesn't mean the same will happen to family medicine. 

I honestly don't think extra training is the answer when you have NPs starting to gain traction with full prescription prvilieges, independent practice, and approval from the public with far less training. I think ultimately, family docs need to subspecialize ina  specific niche area (obs, geriatrics) but also offering comprehensive care as a family health team. This all in compassing, all in one family doctor is a thing of the past in my honest opinion. 

[Edict]

On 3/30/2022 at 11:03 PM, 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.

While I agree family doctors need to advocate for themselves, there are weaknesses to your argument that should be pointed out for the sake of understanding what the government sees vs what we see.

1. FM spots going unfilled just means they get filled by IMGs, so the government doesn't care that much

2. The 3rd year of US FM training is not 12 months of money making lectures, it doesn't take that long. They learn valuable skills needed to become more comprehensive physicians. What the government sees is that Canada has the least training for fam docs in the world and gives them the most responsibility. Lets be real here, being a family doctor in Canada is 10x the sweeter deal than it is in the US. In Canada, family doctors own primary care, you essentially have to see a family doctor to be referred to a specialist and the availability of practice options is much wider in Canada than it is in the US.

3. UK GP training is long for several reasons but the UK system is probably not one any of us would want to emulate anyways

I think asking for a 2 year residency and more money is completely within your right but also not practical. The government is going to demand a concession and imho linking increased compensation for primary care with a 3 year residency incorporating 2+1s isn't a terrible choice.

 

 

[MDee2B]

still a ways away before FM goes to 3 years but does anyone know how this will impact +1's? As in, will the 3 year program mean that everybody will focus on a niche area in 3rd year? Or will a +1 then mean 4 years (3+1) of post grad FM training?

[guy30]

Nothing official has been put out and I don't think the CFPC even really knows how a 3 year FM residency would be structured yet.

 

Who knows how FM fellowships/added competencies would be structured.  Maybe it would be a 3+1 model or maybe they could go the route of how IM residencies work (IM last year of core residency counted towards fellowship) with a 2+2 model for certain CAC programs.  This is since it sounds like the third FM year could be used to develop more focused skills and gain clinical experience in certain areas of interest so this could be potentially rolled into a CAC program (EM, Palliative, primary care obstetrics etc.)

[backinschool]

Does anyone have an update or new info about the implementation and the timeline of the 3 year FM residency?

[frenchpress]

50 minutes ago, backinschool said:

Does anyone have an update or new info about the implementation and the timeline of the 3 year FM residency?

No. Still in early stakeholder discussions/ visioning stages by programs. Won’t be sooner than 2027 if it does ultimately happen. 

[Whattodoo]

On 4/2/2022 at 2:45 PM, hero147 said:

And yet it is almost universally hated amongst all residents in most programs. It also doesn't help that the royal college implemented this crap without robust data on outcomes. Of course implementing a third year or changing the system is easy when it doesn't directly affect the people making the decisions. Are all existing family doctors going to go back for this third year of training? There's definitely a lot of family doctors (and specialist doctors!) that I would trust less than most residents graduating. 

In the spirit of competency based education, residents and their respective preceptors should be able  to discuss a resident is ready to practice independently which does not involve covering all fmaily medicine residents with an extra year willy nilly. Feeling unsure about hospitalist medicine? Maybe apply to do an electie on the wards for 1-2 months after residency. 

I also think somethign has to give. Medicine is growing an exponential rate. You can't possibly learn everything. Are family doctors going to be inresidency for 20 years in 2050? Conversations need to be started about trimming some of the fat in the medical curriculum. God I hope theyre not still teaching the Kreb cycle or Whispering pectoriloquy in medical school 

can confirm whispered pectoriloquy is still a thing in undergrad med ed

[shikimate]

Apparently in the last 3 weeks a lot of physicians online have been discussing about ways to vote for CFPC to reconsider the 3 year residency. I am not part of CFPC so I don't know the details about how to vote but if you search around on FB groups for Canadian physicians/FMD, you should be able to easily find this information