Should Family Medicine be a 3 year residency?

[Edict]

Family doctors are tasked with gargantuan responsibilities and duties and are the backbone of our healthcare system, and yet they make do with only 2 years of PGME. As many say, great family physicians are a rarity and the amount of skill and knowledge needed to become one is immense. What do people think of increasing the length of training for family medicine to 3 years?

 

Privately, I have heard before from family medicine residents that they themselves find it scary that they will be responsible for their patients in such a short period of time. In fact, with family physicians now working as hospitalists, GP anesthetists, obstetrics, surgical assists, shouldn't a 3rd year be added on to give residents further exposure and opportunities to learn and succeed as family physicians?

 

Many specialties are increasing the amount of training required already. For example, internists are now undergoing 5 years of PGME and are often given the same responsibilties towards patients as family physicians working as hospitalists in the community who are only given 2 years of PGME, much of it in the community as opposed to inpatient medicine. 

 

One added benefit would be that the American system would match up with the Canadian one allowing Canadian family physicians to work in the US as well without having to do a +1. 

 

This last year could potentially also be used to do a +1, essentially incorporating the +1 into the family medicine residency. 

 

 

[hamham]

I know several FM programs are already adopting competency-based model. This means that you won't be allowed to graduate from residency until you have completed certain pre-requisites and are deemed "competent" by the program. This would make the length of training irrelevant, though most FM grads need 2 years to demonstrate competency. 

FM residents often claimed that they find it scary, but if you talk to FM staff, most (if not all) actually feel confident of managing their own patient panel after graduating from residency. It's amazing how much knowledge you actually acquire in that mere 2 years. If the graduate continues to find it scary to manage patients, then I would have serious doubts about the quality of training that he/she received at the program.

[freewheeler]

When you're talking about people in medicine who probably range from somewhat to very high-strung for the most part, it isn't unexpected to hear comments about one feeling anxious or perhaps overwhelmed at the idea of managing their own patients.

Of course, with medicine being a profession suited to life long learning, there is always time for FM grads and physicians at large to brush up on their skills, attend to personal learning objectives, etc. It is also possible to seek mentorship from colleagues as a new grad when one chooses their workplace, not to mention doing various extender shifts to help build competency in certain domains.

A larger issue that I have heard reflected to me from staff involved in PGME is that there are a lot of urban family physicians who are practicing in certain niches only--ex. hospitalists, low risk obs, etc. and are not practicing comprehensive FM which can lead to service gaps, fragmented care and can place a strain on those FM docs who are providing comprehensive services.

As far as the GP-anesthetist or GP-surgeon is concerned, those positions are R3 programs already and these positions are limited by the provision of privileges that are often restricted to rural areas.

I think having an optional third year, as is currently available to develop additional competency in specific areas that provide a CAC is sufficient. I would venture that a lot of learning happens during practice after residency, and that will happen regardless of how long the formal residency training period is. Not to mention that one can tailor their learning objectives to their own needs post-residency, which can be more effective than going through another year of some mandatory curriculum that may or may not be synchronous with their personal needs.

[Mithril]

I can't speak for other specialties or programs, but my FM program had a very strong rural component. In that rural component, you learn to basically do everything. You learn to swim. You cannot sink because you won't allow yourself to when you and your preceptor are basically all there is in these far-flung corners of the province. I did not at all feel ready for practice by the end of 1st year residency, but I sure as hell did by the end of 2nd year residency, and I'm still always learning in my first year of practice.

[indefatigable]

I think if it’s going to be a 3 year program, then there’s probably a question of increased remuneration too. Traditionally, I thought training time was one reason many specialties justified their higher  pay.. although I know it’s complicated with psych, peds...  

But then the provinces might not be too happy since its all about containing costs on physician pay.  So while I think there are some advantages in principle, I kind of think it won’t happen because of the financial side and other associated logistical difficulties...  

[Dermviser]

1 hour ago, Edict said:

One added benefit would be that the American system would match up with the Canadian one allowing Canadian family physicians to work in the US as well without having to do a +1. 

 

This last year could potentially also be used to do a +1, essentially incorporating the +1 into the family medicine residency. 

 

 

If you do a +1 in Canada (ie, EM or anesthesia), does that automatically allow you to go to the US and work as an FM doc without any problems?

[hamham]

56 minutes ago, Dermviser said:

If you do a +1 in Canada (ie, EM or anesthesia), does that automatically allow you to go to the US and work as an FM doc without any problems?

I don't think so.

[ralk]

There's a number of changes I would advocate for FM residency programs to improve comfort with independent practice, but a 3 year residency isn't one of them. Most of FM is learning to be comfortable with uncertainty and gaps in knowledge, because there's not enough training in the world to possibly know everything that could fall under an FP's purview right off the bat. As long as a fresh FP has an approach to the common problems, knows where to look information up and/or make referrals when they don't know something, and recognizes when there's a level of acuity that needs to be addressed more urgently than in a clinic setting, that's good enough. The rest can be learned through experience while practicing independently. That's more than achievable in 2 years.

All those other components - hospitalist, obstetrics, surgical assist, GP anesthesia, plus new ones popping up every year - aren't part of core FM, at least not anymore. They aren't necessary to be a fully functional FP in most situations. In fact, most FPs do none of these things, especially in urban centres where most FPs work. The scope of FM is narrowing as specialists (rightfully) take over aspects of medicine GPs used to do more frequently. There's little point in me delivering a handful of babies per year, barely keeping enough volume to maintain competency, when there are more experienced OBs already at the hospital able to do the delivery as well as handle any complications. What's the benefit to me taking care of my own inpatients when beds are at a premium and the internists can do manage them more effectively and quickly than I can? What's the point of me doing a surgical assist when surgeons are lacking work and OR time is limited? Especially at a time when access to FPs in clinic is well below what patients need for proper care. If an FP wants to work in a different setting, there's additional training that is available to do so, but there's little need to get all FPs comfortable in such situations. I'd even argue we over-train FM residents in situations that have little benefit to most graduating FPs (surgery, OB) and could stand to either provide more elective time or put a higher focus on core FM training in offices, nursing homes or - in rural settings - ER and/or rural inpatient care.

Lastly, if we're worried about quality of our FPs, increasing training times would be a huge shot in the foot. A major draw for many students to FM is the shorter training times. I know in my own circumstance, if FM was 3 years, it would have significantly changed by decision-making when it came to CaRMS. Probably wouldn't have driven me away entirely, but it wouldn't have been the clear first choice anymore. If we want great FPs, we need to attract great students, and a 2 year training program is an attractive quality.

[Dermviser]

16 hours ago, hamham said:

I don't think so.

So if I complete FM residency in Canada, how can I transition to the US? Do I need to find a program in the US that would take me on for a year, so I can fulfill the 3-year training requirements?

[indefatigable]

Kudos to the FM docs for making convincing cases for a two year rather than three year residency.  I think there's such a default tendency to simply accept longer training periods as being more desirable, and often inevitable, so it's interesting to read such well-argued opposing viewpoints, especially to people like myself who are not familiar with the intricacies of FM training.  

[goleafsgochris]

18 hours ago, Mithril said:

I can't speak for other specialties or programs, but my FM program had a very strong rural component. In that rural component, you learn to basically do everything. You learn to swim. You cannot sink because you won't allow yourself to when you and your preceptor are basically all there is in these far-flung corners of the province. I did not at all feel ready for practice by the end of 1st year residency, but I sure as hell did by the end of 2nd year residency, and I'm still always learning in my first year of practice.

You are exactly right, but theres a flip side to this.  Programs with strong rural components produce very strong confident GPs, but I did my (non-family) residency in Toronto, and I remember many complaints from Toronto family residents that you can "coast" and learn almost nothing if you don't want to.  I remember one guy telling me that he ended up getting put on a TON of hyper-specialized not relevant rotations, and saying that when your program is 2 years, wasting 6 months on irrelevant stuff in addition to other off service stuff kills the learning.  He said that you could easily see how the urban refer-ologist could develop, especially if you don't have a good mentor that emphasized learning in your clinics.  So there is an opposite end of the spectrum to the intense rural can-do-anything GP.

[Mithril]

29 minutes ago, goleafsgochris said:

You are exactly right, but theres a flip side to this.  Programs with strong rural components produce very strong confident GPs, but I did my (non-family) residency in Toronto, and I remember many complaints from Toronto family residents that you can "coast" and learn almost nothing if you don't want to.  I remember one guy telling me that he ended up getting put on a TON of hyper-specialized not relevant rotations, and saying that when your program is 2 years, wasting 6 months on irrelevant stuff in addition to other off service stuff kills the learning.  He said that you could easily see how the urban refer-ologist could develop, especially if you don't have a good mentor that emphasized learning in your clinics.  So there is an opposite end of the spectrum to the intense rural can-do-anything GP.

Yes, I agree. There are FM programs out there that have way too many off-service rotations where nothing you do is relevant to your future practice. I actively avoided applying to such programs. I wanted a program with a strong rural component so that I could figure out, or know how to figure out, most problems on my own. I don't think a longer duration of residency will help with that, but rather such programs need to cut off the excess useless bloat so that those two years of FM residency are useful and relevant.

[Birdy]

1 hour ago, Mithril said:

Yes, I agree. There are FM programs out there that have way too many off-service rotations where nothing you do is relevant to your future practice. I actively avoided applying to such programs. I wanted a program with a strong rural component so that I could figure out, or know how to figure out, most problems on my own. I don't think a longer duration of residency will help with that, but rather such programs need to cut off the excess useless bloat so that those two years of FM residency are useful and relevant.

Agreed. There is such huge variability in the programs. It was very interesting to see on the interview trail how vastly different the experiences of FM residency could be. There are some very interesting looking program structures designed around optimizing practice-like training as opposed to service based rotations. I really liked a lot of them. 

A big part of my decision to apply for certain programs is my desire to train at sites that don’t have a ton of specialty residents. I’ve seen how the FM residents can just get pushed to the back of the line when there’s a bunch of specialty residents; I can see how it’d be harder for them to get as much out of their rotations as residents at other sites. 

Plus, training at urban sites, you have so many resources! Here in Hamilton, I can think of a litany of clinics, outpatient services, community outreach, resources for family health teams, and so many specialists that handle a huge amount of stuff that, where I will practice, is largely done by family docs. While the FM program here is fine, and I certainly wouldn’t mind training here if that’s where I end up, the residents just won’t have the opportunities to learn a lot of stuff that I will need as a family doc unless they seek them out. 

[Organomegaly]

3 hours ago, goleafsgochris said:

You are exactly right, but theres a flip side to this.  Programs with strong rural components produce very strong confident GPs, but I did my (non-family) residency in Toronto, and I remember many complaints from Toronto family residents that you can "coast" and learn almost nothing if you don't want to.  I remember one guy telling me that he ended up getting put on a TON of hyper-specialized not relevant rotations, and saying that when your program is 2 years, wasting 6 months on irrelevant stuff in addition to other off service stuff kills the learning.  He said that you could easily see how the urban refer-ologist could develop, especially if you don't have a good mentor that emphasized learning in your clinics.  So there is an opposite end of the spectrum to the intense rural can-do-anything GP.

So true. Have tonnes of respect for rural practitioners. Had my obstetrics and gynecology rotation rural. My preceptor managed things not neccessarilly in the purview of his field because there was literally no one else. Even family doctors were short here. Lots of great experience to be gained, but also self-awareness to know when you are in over your head. We often referred patients to the nearest tertiary referral center (London) 

[brady23]

Question to family medicine grads/residents:

I know physical exams are a big component of family medicine, and as a FM, you're probably expected to know a lot of them. Would you say you were comfortable with physical exams during residency or during your clerkship training? For example, being able to identify pathological vs. innocent heart murmurs, lung sounds, etc.? 

The most intimidating aspect to me seems like if I don't know how to do something properly and miss a critical sign as a result. 

 

[ralk]

The urban vs rural divide gets mentioned a lot on these forums, but I'd like to push back against that narrative a bit. It's true, but a bit over-simplistic, because it really depends on how the FM program structures its rotations. There are rural rotations that have tons of rotations in urban, tertiary care environments that give little responsibility to FM residents. Likewise, there are urban programs with off-service rotations away from academic centres that provide plenty of responsibility to FM residents.

It also depends on how your preceptors practice. There's nothing that says an urban practitioner has to be a referologist. Looking back at my own referrals, the only ones that could have been validly kept in an FM clinic were excisions of malignant skin lesions in cosmetically-sensitive areas. I'd love some more experience there, but it's a pretty minor loss to let the experts take care of those. All other referrals have been very clearly indicated by family practice guidelines or require access to resources that no FM physician has, all of which are referrals that should be done by rural FPs as well, despite the challenges of getting patients to those referral locations. That's the misconception I feel gets put to medical students too often - rural FPs have access to the same resources as urban FPs, they're just further away. That's certainly a barrier for many patients, but it's not an insurmountable one, particularly in cases of severe acuity or complexity. One rural doc I worked with made the point that just because specialists are inconvenient to access doesn't excuse trying to make the referral, because specialists are specialists for a reason and rural patients don't deserve worse care just because of where they live.

[ralk]

2 minutes ago, brady23 said:

Question to family medicine grads/residents:

I know physical exams are a big component of family medicine, and as a FM, you're probably expected to know a lot of them. Would you say you were comfortable with physical exams during residency or during your clerkship training? For example, being able to identify pathological vs. innocent heart murmurs, lung sounds, etc.? 

The most intimidating aspect to me seems like if I don't know how to do something properly and miss a critical sign as a result. 

 

A question I got a few times through medical school was "what is the sensitivity/specificity of most physical exam findings?" - and the general answer is that it's pretty low for most exam findings and most conditions. Not zero, certainly, and a thorough exam with tons of little findings can put together the pieces of a puzzle with greater accuracy than any one finding, but even in expert hands a physical exam can be a crude tool. That's why we've developed other tools to help characterize things further. Medicine is struggling with funding, but we're not yet at the point that we can't afford to be extra cautious - if I'm worried about a serious pathology and my physical exam hasn't reassured me, even if it doesn't confirm that something's wrong, I can order testing to investigate further. That'll mean some testing a more experienced person with a more refined physical exam might be able to avoid, but that's part of the learning process too - most FPs over-order tests in the first couple years of practice until they gain the experience and confidence to order less. Specialists do the same - I've seen cardiologists get stumped on a pathologic vs innocent murmur, so they did an echo, no different than an uncertain FP would.

As always, history is the key. Few serious pathologies have innocent histories in addition to subtle physical exam findings. Sick people tend to declare themselves. There's a few exceptions of course, but we do get some focused training around that. Well baby exams, especially within the first 6 months, are probably the one I wish we had a bit more directed training on - some important pathologies can present themselves there in subtle ways that call for early-as-possible intervention and babies can't exactly tell us what's going on.

[bloh]

There is a common misconception that rural docs are better trained. It's very off the mark. They get to handle more stuff but quite poorly. After being trained by some of them and now working with a whole bunch of them, I would strongly recommend to anyone living in a small rural town to just drive to the nearest city and get medical care there. It's worth it.

[F508]

1 hour ago, bloh said:

There is a common misconception that rural docs are better trained. It's very off the mark. They get to handle more stuff but quite poorly. After being trained by some of them and now working with a whole bunch of them, I would strongly recommend to anyone living in a small rural town to just drive to the nearest city and get medical care there. It's worth it.

That's not true either. There are some amazing rural family physicians, that work almost at the level of a general internist. There are also bad family physicians that might "handle things poorly" as you say, but that exists in all specialties in urban and rural centers. Family medicine is an easy specialty to criticize because it's a diverse field made up of a large number of physicians... so inevitably you encounter more "bad" family physicians in proportion.

[bloh]

1 hour ago, F508 said:

That's not true either. There are some amazing rural family physicians, that work almost at the level of a general internist. There are also bad family physicians that might "handle things poorly" as you say, but that exists in all specialties in urban and rural centers. Family medicine is an easy specialty to criticize because it's a diverse field made up of a large number of physicians... so inevitably you encounter more "bad" family physicians in proportion.

You've worked with how many rural physicians in how many communities? I've spent the last 2 years working in more than a dozen different places.

[ralk]

8 hours ago, F508 said:

That's not true either. There are some amazing rural family physicians, that work almost at the level of a general internist. There are also bad family physicians that might "handle things poorly" as you say, but that exists in all specialties in urban and rural centers. Family medicine is an easy specialty to criticize because it's a diverse field made up of a large number of physicians... so inevitably you encounter more "bad" family physicians in proportion.

To me, that's just hubris. If an FP of any stripe thinks they're taking the place of a good, fully trained internist, they're deluding themselves - we simply don't have that depth of training. There are definitely rural FPs who do a good job of taking care of moderate-acuity inpatients, those who require hospitalization but who are relatively simple. And, in urban centres, internists would take care of these patients. But those internists are taking care of much more complex patients as well, and any FP who is holding off referrals or patient transfers because they think they're equal to a general internist is putting their patients at needless risk.

[goleafsgochris]

12 hours ago, ralk said:

The urban vs rural divide gets mentioned a lot on these forums, but I'd like to push back against that narrative a bit. It's true, but a bit over-simplistic, because it really depends on how the FM program structures its rotations. There are rural rotations that have tons of rotations in urban, tertiary care environments that give little responsibility to FM residents. Likewise, there are urban programs with off-service rotations away from academic centres that provide plenty of responsibility to FM residents.

It also depends on how your preceptors practice. There's nothing that says an urban practitioner has to be a referologist. Looking back at my own referrals, the only ones that could have been validly kept in an FM clinic were excisions of malignant skin lesions in cosmetically-sensitive areas. I'd love some more experience there, but it's a pretty minor loss to let the experts take care of those. All other referrals have been very clearly indicated by family practice guidelines or require access to resources that no FM physician has, all of which are referrals that should be done by rural FPs as well, despite the challenges of getting patients to those referral locations. That's the misconception I feel gets put to medical students too often - rural FPs have access to the same resources as urban FPs, they're just further away. That's certainly a barrier for many patients, but it's not an insurmountable one, particularly in cases of severe acuity or complexity. One rural doc I worked with made the point that just because specialists are inconvenient to access doesn't excuse trying to make the referral, because specialists are specialists for a reason and rural patients don't deserve worse care just because of where they live.

Oh for sure, theres a HUGE breadth, and I'm sure that breadth exists both in urban and rural settings.

The thing about urban GPs though (especially in major centers) isn't that most of them coast, but that its POSSIBLE to coast.  Like if you want (and again, most don't), you can join a downtown practice and essentially sleepwalk through almost everything, doing routine stuff and referring anything remotely out of the basics.  There are enough specialists in the cities that they don't mind the "basic" referrals added into the mix.  Again, most GPs care and don't practice like that.  But the fact that there is a huge range of GPs, and out of any population of any job some people will take the easiest route possible, and it is POSSIBLE to practice like that in an urban setting if you want to just sort of phone it in, is a real thing.  Doing that rurally would be more difficult.

[A-Stark]

22 hours ago, bloh said:

There is a common misconception that rural docs are better trained. It's very off the mark. They get to handle more stuff but quite poorly. After being trained by some of them and now working with a whole bunch of them, I would strongly recommend to anyone living in a small rural town to just drive to the nearest city and get medical care there. It's worth it.

It varies of course. I've taken lots of outside calls where my decision making amounted to "You don't seem to have any idea what's going on but the patient sounds sick, so better send them in". But that's not always the case. With one call from last weekend, the local doc gave a pitch perfect story of heart failure, treated it with fluids, bronchodilators and prednisone, and the patient improved. I have no idea what was really going on! But really I think suggesting rural family docs are doing things "quite poorly" is far too much of a generalization. My other calls were pretty reasonable. 

21 hours ago, F508 said:

That's not true either. There are some amazing rural family physicians, that work almost at the level of a general internist. There are also bad family physicians that might "handle things poorly" as you say, but that exists in all specialties in urban and rural centers. Family medicine is an easy specialty to criticize because it's a diverse field made up of a large number of physicians... so inevitably you encounter more "bad" family physicians in proportion.

Perhaps there's a few old school GPs that are particularly knowledgeable, but it's very much the exception. That GIM knowledge doesn't appear from just putting in a couple more years in training, but from that exam (and spending a year studying for it). I've seen plenty of referrals from rural and urban family physicians alike that fall into one of two categories: (1) they have no idea what's going on but recognize Something is Wrong, so they refer; (2) they have no idea what's going on and we end up doing a Holter or a non-contrast CT head or some other low yield investigation because Tests. 

I have found that emerg consults tend to be a lot more sensible in smaller centres. 

As to the original question, I'm a proponent of general licensure and think that the elimination of the rotating internship has harmed career flexibility and generalism. That we've gotten to the point of having direct entry residencies for things as specific as vascular surgery underlies this. 

[F508]

Sorry, yes I meant that some work at the level of an internist for moderate-acuity inpatients. Obviously, I don't think you can get to the level of a full fledged internist with only 1-2 rotations of internal medicine in residency.

[GrouchoMarx]

the problem is four year schools persist when there is evidence that three year schools produce doctors of the same competence. imo the fourth year of medical school is vestigial.

my model would be like this: every student would complete:

3 years of medical school

2 years of family medicine residency

royal college specialty residency if you want.

 

there. everyone gets to practice as a family doctor if they want. specialists will have gone through family and understand the perspective of family doctors. everyone has more mobility. specialists with poor job prospects could do family medicine in the meantime. i cant see any real downside.

sure some of the specialists will disagree with me saying that it adds on years to their training, but i would argue that it doesnt. the family residency would act as an internship in most cases. in some, such as surgery, well, who cares. its a sacrifice. and given the job market for things like ortho, maybe theyd be better off.