Vol 55: april • aVril 2009 Canadian Family Physician•Le Médecin de famille canadien
For some years, universities and other organizations have questioned the length of specific training in family medicine, which is currently 2 years. Four years ago, the Collège des médecins du Québec asked the Fédération des médecins omnipraticiens du Québec to weigh in on this subject. At the time, we said that the 2-year residency was long enough and, based on the considerations I discuss below, we still think that it is sufficient.
There is no indication from the pass rate on the end-of-residency examination that there are gaps in the knowledge and skills of residents completing their 2-year training. The reason most often given for exten- ding the family medicine residency is that residents do not feel confident in their knowledge of the range of sub- jects that their profession, by its nature a multifaceted one, will require of them. At first glance, increasing the length of their training might seem like the right res- ponse to the need for an increasingly broad knowledge base. However, the various efforts that have been made in this direction actually lend support to the view that extending their training is not the answer.
Loss of a more typical multifaceted practice
Let us consider the example of the third-year programs currently offered in Quebec and in Canada that culmi- nate in a certificate in emergency medicine, palliative care, or geriatrics. More often than not, the net result of this approach is a targeted—even an exclusive—practice in one of these fields, at the expense of a more typical multifaceted family medicine practice. Unfortunately, the pursuit of this approach further exacerbates the shortage of family medicine “generalists.” Graduates adopt a narrower scope of practice from the beginning instead of narrowing their focus gradually over time, as happens with most family physicians.
Sweden has often provided prototypes for practices that are adopted in other countries because of its inno- vative approach. In introducing a 3-year family medicine residency, associated with a 5-year tutorship leading to certification, Sweden extended its family medicine
training considerably. There can be no doubt that the residents acquire more knowledge in this program, which, in length, comes close to our longest residencies (ie, 6 years in cardiology, cardiovascular surgery, thora- cic surgery, and neurosurgery). Extending the training in this way, however, would lead to a 1- to 3-year halt in the production of new family physicians. The immediate result would be a substantial drop in the availability of family physicians who are already in short supply. Recall that, last year, their ranks grew by a mere 61 family phy- sicians in Quebec.
According to the largest Canadian study ever of family medicine, conducted by Dr Marie-Dominique Beaulieu, the Dr Sadok Besrour Family Medicine Research Chair at the University of Montreal, these “super residents”
would reinforce the model of an “omniscient” physi- cian—a model that young residents and students in medicine find unrealistic, if not terrifying.1 For them, the generalist does not approach his or her work by taking on every single medical problem; he or she “manages any problem that comes up,” which might involve refer- ral to another health specialist. In this manner, family physicians “orchestrate the various forms of care that are being delivered in an increasingly complex health care system.”1
Many ways to support and reassure new family physicians
The insecurity that new family physicians quite natu- rally feel in response to the range of skills that their profession demands of them can be addressed through a variety of measures. I have divided these measures into 3 groups: organizational skills, access to support on an as-needed basis, and adapted, ongoing profes- sional development. A group practice is a great source of support, providing opportunities to discuss cases for- mally and informally and opportunities for mentoring, as is now the case in obstetrics. Access to the diagnos- tic and therapeutic resources of the health care system, the ability to search for information electronically, and rapid access to the advice of experts thanks to an inter- disciplinary working environment represent other ways
Should family medicine residency be 3 years?
continued on page 344 Cet article se trouve aussi en français à la page 347.
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344Canadian Family Physician•Le Médecin de famille canadien Vol 55: april • aVril 2009
(Marshall and Tennessee5,6) ran a 2-year residency pro- gram as a pilot project. The residents did better on their examinations; however, these programs only admitted a small number of residents who were older and who had better-than-average academic records.
It is time Canada understood the challenge
It is a mistake to think of the current residency program as a 2-year program. The collective agreements governing resi- dents in Quebec have improved; residents are now allowed more than 50 working days leave per year, exclusive of sick leave.7 The residency is barely 19 months long. When a resident is on call (every 4 days in Quebec), he or she is off the next day. This means that residents can be absent from their rotation settings for a total of 15 weeks in a year. The result? A residency of 1 year and 7 months, during which residents are only in their rotation setting for 13 months!
Thirteen months is not enough to train a physician in a specialty that, in my opinion, is one of the most complex and demanding there is! Other industrialized nations have understood the challenge. Canada’s fam- ily physicians also deserve a minimum of 3 years of training.
Dr Lehmann has practised medicine for 39 years and is currently the Director of the Department of Family Medicine at the University of Montreal in Quebec.
Competing interests None declared Correspondence
Dr François Lehmann, Department of Family Medicine, Faculty of Medicine, University of Montreal, PO Box 6128, succursale Centre-ville, Montreal, QC H3C 3J7;
telephone 514 343-6497; fax 514 343-2258; e-mail firstname.lastname@example.org references
1. Haq C, Ventres W, Hunt V, Mull D, Thompson R, Rivo M, et al. Family practice devel- opment around the world. Fam Pract 1996;13(4):351-6.
2. Garnier E. Un nouveau président à la tête de la FMOQ. Le Médecin du Québec 2008;43(1):1-3, 12.
3. Lebensohn P, Campos-Outcalt D, Senf J, Pugno PA. Experience with an optional 4-year residency: the University of Arizona family medicine residency. Fam Med 2007;39(7):488-94.
4. Winter RO. How long does it take to become a competent family physician? J Am Board Fam Pract 2004;17(5):391-3.
5. Petrany SM, Crespo R. The accelerated residency program. The Marshall University Family practice 9-year experience. Fam Pract 2002;34(9):669-72.
6. Delzell JE Jr, McCall J, Midtling JE, Rodney WM. The University of Tennessee’s accel- erated family medicine residency program 1992-2002: an 11-year report. Fam Pract 2005;37(3):178-83.
7. Fédération des médecins résidents du Québec. Entente collective 2007-2010.
Montreal, QC: Fédération des médecins résidents du Québec; 2007.
to support and reassure family physicians. A system in which each general practitioner manages his or her own professional development is another supportive measure, particularly if ongoing professional develop- ment can be accessed without financial penalty and at a reasonable cost, if it involves practice support tools that are readily available, and if it addresses needs expe- rienced by individuals, groups, and the interdisciplinary team as a whole.
Last, let’s look for a moment at the experience in France, where extending the training for front-line medi- cine has led to a specialization in practice in various fields, notably hospital care. This process has exacerba- ted the shortage of front-line medical resources, adding to the image of front-line care as the “poor cousin” of the health care system.
In Quebec, the percentage of family physicians who are active in second- and third-line care is already quite high: 39%. Our French counterparts were limited to front-line care and were not allowed to acquire the sta- tus of “hospitalists.” Now that they are allowed to deli- ver hospital care, the shortage of staff on the front line continues to worsen. This is a pattern we see in Quebec with new family physicians who have completed exten- ded training in a specific, narrower field.
Dr Raîche is the Director of Professional Training of the Fédération des méde- cins omnipraticiens du Québec.
Competing interests None declared Correspondence
Dr P. Raîche, 1000-1440 rue Sainte-Catherine, Montreal, QC H3G 1R8; tele- phone 514 878-1911; fax 514 878-4455; e-mail email@example.com reference
1. Beaulieu MD, Rioux M, Rocher G, Samson L, Boucher L. Family practice: pro- fessional identity in transition. A case study of family medicine in Canada.
Soc Sci Med 2008;67(7):1153-63.
Unless we can identify some need to correct a situ- ation that is alarming or disturbing now or later, the current length of the specific training in family medicine is adequate and sufficient.
YEScontinued from page 342
NOcontinued from page 343
Three years is the minimum length of training for family physicians in every industrialized nation except Canada.
Family medicine is one of the most complex and demanding specialties there is. Pathologies are more numerous and more complex than they once were;
there is a wider range of therapeutic options; and family physicians must now acquire, in addition to traditional skills, new cross-disciplinary and com- munication skills.