"Family Medicine in Decline"

March 5, 2003

Just watched the news at noon and CARMS stats are out. There was a noon time exposee on family medicine which noted how this year was a Canada wide record low for residency applicants to Family medicine (24%) down from 30% three years ago....slowly slipping...

Reasons cited:

1) unglamorous

2) not lucrative ($$$ I imagine)

3) not important

Have people failed to forget that family physicians (GP's) are the gateway to the medical system? Yes they are overworked, but who isn't these days?

Any thoughts?

Edited to change the title a bit. -Ian

March 5, 2003

I agree that family medicine is (should be) the cornerstone of our healthcare system. Given that the majority of diseases facing Canadians are chronic in nature (cardiovascular diseases, cancer, diaebetes, etc) you need a system to manage these individuals on an ongoing basis. More importantly, you are in a position to affect change in the lifestyle characteristics which lead to many of these diseases.

BTW do you know what the trend is in other not-as-lucrative fields? If they don't follow the same trend then it says something about the other reasons cited for the decline in family apps.

March 5, 2003

Here's an article in today's Globe and Mail commenting on the above position of Family Medicine. The news is not good AT ALL, and the trouble is that the trend away from FM as a career choice for medical students is continuing. It's also a vicious cycle, because as med students gain exposure to over-worked and unhappy family doctors, they are less likely to want to place themselves in that position by choosing Family Medicine, and this perpetuates the ever-increasing workload and lack of recruitment of this career path.

Of the students who do enter Family Medicine, more and more of them are shying away from establishing a full practice with office staff and a fixed pool of patients. More and more are doing part-time work as locums, or taking shifts in walk-in clinics, or using the Family Medicine degree as an avenue towards the 3-year Emergency Medicine residency.

Oh yeah, and I moved this thread out of the General Premed forum into the Med Student's forum...

Ian

www.globeandmail.com/serv...y/National

Family doctors in decline

By ANDRÉ PICARD

From Wednesday's Globe and Mail Wednesday, Mar. 5, 2003

If you think finding a family doctor is difficult today, just wait a few years: Family medicine has become so unpopular that almost one-third of residency positions for future general practitioners are unfilled.

New data show that only 24 per cent of medical students chose family medicine for their residency training this year. And many university hospitals failed to fill even half the spots that were allocated to the training of general practitioners, according to numbers published Tuesday in e-CMAJ, the online news service of the Canadian Medical Association.

"There appears to have been a complete disengagement from family medicine," said Sandra Banner, executive director of the Canadian Resident Matching Service.

Calvin Gutkin, CEO of The College of Family Physicians of Canada, said the data are disturbing and mean big trouble for patients in years to come.

"The future of family doctors being available in this country is in jeopardy," he said.

Students' disinterest stems from poor working conditions and the "perception that it's become too hard to become a family doc" because the hours are too long and the prestige too low, he said. There's a feeling that GPs are second-class physicians, compared with specialists.

Last year, a poll released by the college suggested that 4.5 million Canadians — about 15 per cent of the population — do not have family doctors.

In his report, Roy Romanow, chairman of the Commission on the Future of Health Care in Canada, called the situation "absolutely untenable" and said governments must act swiftly to reform primary care. He said timely access to family doctors is a key to sustaining medicare.

Medical training takes place in three phases: academic learning, a period of internships in which students train in a number of areas and residency, where students train on the job in a chosen specialty.

This year, there are 484 residency-training positions in family medicine, and 139 are unfilled. At the same time, 115 students are "unmatched," meaning they did not get residencies in their chosen fields.

Ms. Banner said the unmatched are unlikely to turn to family medicine but likely will seek specialty training in the United States.

Danielle Martin, president of the Canadian Federation of Medical Students, told e-CMAJ that the declining interest in family medicine is due principally to the view that it is a second-class career choice.

"It all comes back to the perception that this is not a sexy field," she said.

Ms. Martin said that lifestyle considerations are also important: Increasingly, GPs cannot necessarily practice where they choose and, because of shortages, often have to work long hours. Specialists, on the other hand, usually can work regular office hours and earn much more money and more respect.

However, Ms. Martin, a fourth-year student at the University of Western Ontario, is bucking the trend and will do her residence in family medicine, saying it is a challenging and rewarding field. But she believes that changes have to be made to make family medicine more attractive.

"We have to make it affordable for people to make socially responsible choices, and yes, I consider choosing family medicine is socially responsible because our system depends on it," Ms. Martin said.

About half of Canadian physicians are specialists, while the balance are general practitioners and family physicians. However, almost two-thirds of requests for residency training are for specialties.

According to Statistics Canada, physicians in this country earn an average of $105,200 a year. Specialists earn, on average, 18-per-cent more than generalists — $116,500 versus $98,700. But the top 5 per cent of wage earners, those who bring in $250,000 or more, are almost all specialists in areas such as dermatology and ophthalmology.

March 5, 2003

Here's the CMAJ article referenced in the above Globe and Mail discussion. They comment that two other specialties (Anesthesia and Obs/GYN) have rebounded in popularity over the past several years. Anesthesia, in particular, has become a "hot" specialty over my med school time in the last 3-4 years. Unfortunately, a lot of that is because of its perception as a "lifestyle" specialty. Ob/GYN is one to watch because I think this is the first year where the competitiveness went up substantially, so it will be interesting to see if this trend continues in subsequent years.

Ian

www.cma.ca/cmaj/cmaj_toda.../03_04.htm

Family medicine attracts smallest-ever share of residency applicants

Date: March 4, 2003 Time:9:27 am

Three years ago, when the proportion of medical students making family medicine their first residency choice dropped below 30% for the first time, program directors called it "a blip."

This year they will have to think up a new word, because the proportion has dropped to 24%.

After the first round of the 2003 residency match was completed on Feb. 27, 139 of 484 training positions in family medicine — 29% — remained unfilled, with one-third of the 36 programs filling 50% or less of their spots. "Family medicine has seen a major drop in popularity," says Sandra Banner, executive director of the Canadian Resident Matching Service (CaRMS).

Data from the 2003 match tell a depressing tale. For instance, the number of unmatched students — 115 — was 3 times higher than last year, but almost all of them are seeking specialty training. And Banner says few of the unmatched students will seek a family medicine slot in the match's second iteration, since most do not consider it a career option. Many will likely seek specialty training in the US.

As well, even though 114 more students registered with CaRMS for this year's first iteration, the number matched to family medicine actually declined by 35, to 296 students. "There appears to have been a complete disengagement from family medicine," says Banner.

But not everyone has been disengaged. Danielle Martin, a fourth-year student at the University of Western Ontario and president of the Canadian Federation of Medical Students, matched with the family medicine program at the University of Toronto. "I never wanted anything but family medicine," she says.

Martin says there are many reasons for students' declining interest in family medicine, but the perception that it is less prestigious than other specialties has become a major factor. "It all comes back to the perception that this is not a sexy field," she says. "Most of my classmates who did rural medicine electives really enjoyed them, but then they went ahead and chose specialties."

Martin is also concerned about the denigrating comments she heard about family medicine at medical school. "During my clerkship year, one of my preceptors said I was way too smart to be a family doctor. And you'd hear things like 'the family doctor screwed up, and then the patient was taken to a real doctor.' " She thinks student debt is also entering the equation when career choices are being made, with high debt loads encouraging students to seek out higher-paying specialties. As well, some are opting for "lifestyle" specialties that offer more regular practice hours than family medicine.

Martin says the combination of lower incomes for FPs and the message that family medicine is the least prestigious medical career is a recipe for disaster. "We have to make it affordable for people to make socially responsible choices and, yes, I consider choosing family medicine is socially responsible, because our system depends on it."

Dr. Cal Gutkin, CEO at the College of Family Physicians of Canada (CFPC), says the college has been developing a response since the problem first appeared about 3 years ago. Attempts so far have included meetings with medical students and a program to bring students to the CFPC's annual meeting. Meetings have also been held with deans of medicine, and in February the college met with government leaders to make them aware of the problem. "We have to act immediately," Gutkin says. "If we accept 24%, then we're accepting that the whole system has to change."

Dr. Claude Renaud, former director of professional affairs at the CFPC, thinks family medicine "is under the gun on all sorts of levels" because of primary care reform. "Insecurity has been building for 5 or 6 years because of talk about 24/7 coverage and increased roles for nurse practitioners and pharmacists, and I think students have started to view family medicine as less of an important role," says Renaud, now chief medical officer at the CMA. He thinks the future of generalists is being threatened by "the glamour of the subspecialties," and this holds serious implications for a medicare system that relies on a 40-60 split between primary care physicians and specialists. "If we were to lose the balance we have, the system won't function," he says. "We need the gatekeepers."

Although most of the 139 vacant family medicine positions will be filled in the second round of the match, which is open to international medical graduates, Renaud says this year's bleak first-round results shouldn't be ignored. "They show that family medicine is no longer being viewed as an ideal as it used to be," he said.

However, the family medicine brain trust can take heart because 2 specialties appear to have overcome rising unpopularity in recent years. This year all 66 positions in anesthesia were filled in the first round of the match, but as recently as 6 years ago, 20% were being left unfilled. And obstetrics/gynecology filled 48 of 49 positions, a distinct improvement over 1999, when 12 of 49 slots were unfilled after the first round. Banner said these results "mark a real turnaround," which may be attributable to the completion of hospital restructuring in most parts of the country.

"We've done very aggressive promotion this year," added Andrée Poirier, director of communications with the Society of Obstetricians and Gynaecologists of Canada. "Our members were present during career nights, and we sent letters to second- and third-year students. I think these proactive measures have helped."

— Patrick Sullivan, eCMAJ

March 5, 2003

CBC Radio ran a program yesterday regarding the plight of Family Medicine. They interviewed 2 graduating med students (one from U of Manitoba, and the other from UWO), as well as Cal Gutkin, the CEO of the College of Family Physicians of Canada . You can download a RealMedia copy of the radio interviews from the links below; the total length of the program is about 20 minutes.

Ian

Here's more information on it:

cbc.ca/thecurrent/2003/200303/20030304.html

Whole Show Blow-by-Blow

The Current for Show March 4, 2003

Family Doctor Shortage--medical student panel

A falling percentage of graduating medical students across Canada are choosing family medicine as their specialty. This could make the doctor shortage problem worse.

Family Doctor Shortage---Doctor

Dr. Cal Gutkin says the med students could have a serious impact on the availability of family doctors because it underlines that med schools and governments are not doing enough.

Family Doctor Shortage--Fact Board

The number of Canadian doctors peaked 10 years ago. It's declined by 5% since according to the Canadian Institute for Health Information. Over the past decade, British Columbia has had the highest ratio of doctors per capita. To maintain that standard BC needs an 300 new physicians every year. Its medical schools can't fill that quota. Right now fewer than 150 graduate every year. There are fewer spots for medical students at schools across the country.Those placements were cut by ten percent between 1993 and 1997 And once they graduate there's no guarantee a doctor will stay and practice in this country. 585 doctors left Canada in 1999, only 34 returned. In the same year a report commissioned by the Ontario government said the province was short approximately one thousand doctors ... a shortage that is projected to increase to almost three and a half thousand by 2010.

Listen to The Current: Part 1

Unfortunately, you need Real player to hear the above. (Download it from the right-hand side of your screen).

March 5, 2003

Here's another article out of the Vancouver Sun, again stating some of the dismal statistics regarding entering Family Medicine, and possible reasons for this.

Ian

www.canada.com/news/story...ADFE4CF7A}

Shortage of family doctors may worsen as med students flee the field

HELEN BRANSWELL

Tuesday, March 04, 2003

TORONTO (CP) - Think it's hard to find a family doctor now? The problem may only get worse.

The organization that matches would-be doctors to residency positions says the percentage of students who listed family medicine as their first choice in this year's process is the lowest they've ever seen.

Only 24 per cent of students opted for family medicine, which makes up roughly 40 per cent of the 1,317 training spots in the country's 36 English-language medical schools for next fall, said Sandra Banner, executive director of the Canadian Resident Matching Service.

"Over a 10-year span it's been slowly declining. I think the thing about this year is that it was a significant drop," Banner said from Ottawa.

Three years ago, when the figure dropped below 30 per cent for the first time, alarm bells rang throughout the system. But the dip was dismissed as a blip. Since then, the numbers have continued to decline.

The first round of the matching process for next fall was completed on Feb. 27. The second round, which will place 116 unmatched applicants and some other students who qualify, is still to come.

Some of the remaining students will go into family medicine. But that doesn't change the fact that as a field, the popularity of family medicine is on the wane, Banner said.

"There's the issue. Not whether or not we will fill the positions anyway, but rather that the students do not see family medicine as a career."

The president of the Canadian Federation of Medical Students finds this evidence worrisome.

Danielle Martin is a fourth-year medical student at the University of Western Ontario. She graduates this spring and has secured a residency in family medicine at the University of Toronto for the fall. The idea of being a family doctor is what drew her to medicine in the first place, Martin said.

But she believes family medicine gets short shrift in medical schools, where specialties like surgery or emergency medicine are considered more glamorous, more lucrative, more important.

Lectures on most subjects are taught by specialists, a situation that could leave students with the impression that family doctors are little more than gatekeepers between patients and specialists, she said.

As well, some of those lecturers display disdain towards family medicine, Martin said.

"I got told more than once by specialists: 'You're too smart to be a family doctor.' That's a pretty scary attitude.

"If you hear that and you're at all wavering in your decision as to which way to go and the subliminal and sometimes overt messages that you're getting from people is that the smart ones go into specialties and family medicine is for people who can't hack it in the specialties, then that is going to influence people's decisions."

Financial considerations increasingly are playing a role, Martin added. Medical students rack up a staggering amount of debt during their long years of schooling and paying that down weighs on their minds.

"I don't think there's an epidemic of that yet but I think a lot of people are heading in that direction," she admitted.

"I don't think it's because they're selfish or bad doctors, I think it's because when you're facing a $100,000 debt, a lot of things go into your career decisions and finances have to be one of them."

March 5, 2003

Yeah, this was one of the top news items on CTV Newsnet as well.

March 5, 2003

Yet another article, this time by the National Post. It's great to see all the attention that this has generated in today's newspapers. I can only hope that this sort of publicity doesn't immediately fade back into obscurity, and that someone starts taking a long, hard look at how to rectify and improve this situation.

Ian

www.nationalpost.ca/home/...D67F50C78}

Lure of lucrative specialties endangering family medicine

Heather Sokoloff

Wednesday, March 05, 2003

Fewer Canadian medical students than ever want to work as family doctors, opting instead for glamorous and lucrative careers as cardiac surgeons or ophthalmologists.

Family medicine remains the largest medical speciality, but the numbers are dropping significantly, making Canada's family-doctor crisis even worse.

Only 24% of Canadian medical students are seeking training as family doctors or general practitioners this year, down from 30% last year and 40% a decade ago.

Dr. Calvin Gutkin, CEO of the College of Family Physicians of Canada, says students shun the profession after learning family doctors are paid the lowest salaries in medicine but work gruelling schedules, averaging 72 hours a week.

''Our governments and our medical schools have not stressed the value of family medicine in our Canadian health care system,'' said Dr. Gutkin, a family doctor since 1973.

"We need family doctors."

Almost 30% of the training positions in family medicine are currently unfilled, according to the Canadian Resident Matching Service, the organization that matches students from Canada's 36 English-language medical schools with 1,317 residency positions across the country.

Ontario, for example, needs 500 family doctors right now. But those vacancies will be insignificant compared to what will happen if students keep rejecting family medicine, warned Dr. Douglas Mark, the president of the Coalition of Family Physicians and deputy chief of family medicine at Toronto's Scarborough Hospital.

"It will be harder and harder to get a family doctor. People will be going from walk-in clinic to walk-in clinic," he predicted.

Dr. Gutkin says even though most of the family medicine training spots will eventually be filled, the drop in interest signals a looming crisis as more and more Canadians will be forced to go directly to the emergency room when they have an injury or illness and wait hours to see a doctor they have never met before.

Family doctors feel abused by a health care system that is increasingly demanding they care for growing numbers of patients in an ageing population as well as take responsibly for patients who are sent home instead of being cared for in a long-term facility, he added.

Danielle Martin, a third-year medical student at the University of Western Ontario who will enter a family residence training program at the University of Toronto next year, said the profession is given little respect by other physician specialists.

The specialists who teach her medical school classes said she was ''too smart to be a family doctor,'' an attitude she thinks causes medical students to believe family doctors end up working as generalists because they could not gain acceptance into training programs for other specialties.

''You'd hear things like, 'The family doctor screwed up, and then the patient was taken to a real doctor.' ''

Ms. Martin, president of the Canadian Federation of Medical Students, said medical students have little interaction with generalists, even though family doctors are the first to diagnose illness when they meet a patient.

''More than 90% of lower back pain is treated by the family doctor, yet when we are taught about lower back pain, we get taught by neurosurgeons.''

Another reason is that debt-strapped students are seeking lucrative specialties such as opthamology so they can quickly pay off their student loans, or specialities such as dermatology or plastic surgery that do not demand miserable hours.

Dr. Heather Tick, a family physician who has worked in Toronto for 20 years, says many of her colleagues are abandoning their practices to take private-sector jobs at nursing homes or with health insurance companies.

'All of my colleagues are burned out," she says. "I don't know one who isn't. Students look at us and say, 'Why bother?' ''

A poll for the College of Family Physicians of Canada last October found that 4.5 million Canadians over the age of 18 don't have a family physician.

March 5, 2003

Here's one from the Ottawa Citizen, with some insightful comments not seen elsewhere, such as 80-90% of Family Medicine graduates not immediately starting a practice, but rather doing locums and walk-in clinic work (leading to a delay between when a Family Medicine resident graduates from residency, and when they assume full-time work in the community). This article is a little messed up in that whoever put it on-line accidentally duplicated parts of the article, but otherwise is a really good read.

Ian

www.canada.com/ottawa/ott...D8323B6E47

Students reject family medicine

Already needing 500 more GPs, Ontario sees shortage worsening

Joanne Laucius

The Ottawa Citizen

Wednesday, March 05, 2003

A record proportion of Canada's medical students are saying no to family medicine. And that means it will be harder than ever to find a family doctor.

Only 24 per cent of the students made family medicine their first residency choice this year -- a drop of more than five per cent from last year.

If the system is to remain in balance, about 50 per cent should choose family medicine in the first round of matches.

But this year almost a third of the training positions in family medicine -- 139 out of 484 -- remain unfilled after the first round. And the Canadian Resident Matching Services believes many of the 115 unmatched students will seek specialty training in the U.S. instead of choosing family medicine in Canada.

Ontario needs 500 family doctors right now.

But those vacancies will be insignificant compared to what will happen if students keep rejecting family medicine, warned Dr. Douglas Mark, the president of the Coalition of Family Physicians and deputy chief of family medicine at the Scarborough Hospital.

"It will be harder and harder to get a family doctor. People will be going from walk-in clinic to walk-in clinic," he predicted.

About 80 to 90 per cent of newly minted family doctors are filling in for other doctors or working in walk-in clinics, he said. That means that there will be only 20 or 30 new doctors starting family practices in Ontario each year.

Even the Canadian Medical Association Journal has taken note, publishing the figures on its Web site yesterday in advance of its next print edition.

The factors driving away students are many -- the overhead costs of running a family practice, lower pay than specialists, an increasing administrative load and sometimes the lack of prestige and recognition.

In recent years, student interest in family medicine has dropped to alarming levels. The figure dropped below 30 per cent for the first time in 1999. Since then, the figures have hovered around 30 per cent.

However, the 2003 figure is a "significant" drop from that level, said Sandy Banner, the executive director of the Canadian Resident Matching Service.

"Interest has been eroding," said Ms. Banner. "It's a complex problem. It won't solved easily."

Mona Shafey, a fourth-year medical student at the University of Ottawa, has been accepted for a residency in internal medicine, her first choice of speciality.

"If you're going to do the work, you might as well get paid," she said.

Ms. Shafey has had three placements in family medicine so far. She has noted that there is a lot of frustration among family doctors.

"Paperwork is horrendous," she said. "We see physicians sitting there for hours filling out forms. And they're not happy about it."

About a decade ago, close to 50 per cent of medical students were interested in family medicine, said Dr. Mark.

But high tuition levels and student debt averaging $100,000 is drawing students toward specialties. Family doctors are paid about 55 per cent of what specialists are paid, he said.

After overhead costs, the average income for a family doctor is $99,000 with no benefits and work weeks often in excess of 50 hours, he said. "We want to be fairly funded for the education we have."

The bodies that represent family physicians already know they have a big problem. A poll for the College of Family Physicians of Canada last October found that 4.5 million Canadians over the age of 18 don't have a family physician.

The college is already urging Canada's 16 medical faculties to include more family medicine in the curriculum.

But more needs to be done, said college CEO Dr. Cal Gutkin. "Medical schools have to give family practice the prestige, so medical students see it as equal to specialities."

He believes the college will also have to put out an appeal to the 115 students who don't have a residency match so far.

"They should seriously consider it as an opportunity," said Dr. Gutkin. "We need family doctors."

Danielle Martin will start a residency in family medicine at the University of Toronto in July. Despite a $100,000 debt, she's determined to be a family doctor.

"The relationship between patients and doctors is not replicated anywhere else in the medical system. It's based on trust," she said. "It's an honour."

But those vacancies will be insignificant compared to what will happen if students keep rejecting family medicine, warned Dr. Douglas Mark, the president of the Coalition of Family Physicians and deputy chief of family medicine at the Scarborough Hospital.

"It will be harder and harder to get a family doctor. People will be going from walk-in clinic to walk-in clinic," he predicted.

About 80 to 90 per cent of newly minted family doctors are filling in for other doctors or working in walk-in clinics, he said. That means that there will be only 20 or 30 new doctors starting family practices in Ontario each year.

Even the Canadian Medical Association Journal has taken note, publishing the figures on its Web site yesterday in advance of its next print edition.

The factors driving away students are many -- the overhead costs of running a family practice, lower pay than specialists, an increasing administrative load and sometimes the lack of prestige and recognition.

In recent years, student interest in family medicine has dropped to alarming levels. The figure dropped below 30 per cent for the first time in 1999. Since then, the figures have hovered around 30 per cent.

However, the 2003 figure is a "significant" drop from that level, said Sandy Banner, the executive director of the Canadian Resident Matching Service.

"Interest has been eroding," said Ms. Banner. "It's a complex problem. It won't be solved easily."