Ontario, Quebec and Alberta lead record family medicine residency vacancies

Primary care reform needed

“Med schools and the hidden curriculum, which teaches that family medicine is a less desirable choice,” bear some responsibility for this mismatch in supply and demand, according to Jane Philpott, dean of Queen’s University’s faculty of health sciences and former federal minister of health. “But more importantly, it’s about the primary care system, which needs a radical overhaul.”

Transitioning to team-based primary care models, which provide better work–life balance for clinicians and enable them to delegate tasks that can be done by other health professionals, “is the fundamental fix that we need,” Philpott tweeted.

With more than 6.5 million Canadians currently lacking family care providers, she called for a “loud public outcry” and political will at all levels of government to ensure everyone has a primary care team.

According to Ontario College of Family Physicians president-elect Jobin Varughese, many medical trainees don’t see the predominant fee-for-service model as one that works for primary care.

Medical training often takes place in team-based care environments where learners experience the benefits of collaborating with other professionals, making the transition to fee-for-service family practice a tough sell, Varughese said.

“They’re used to seeing maybe four or five people an hour, and now they’re asked to see six to eight people an hour and expected to keep the same level of quality of care. Nobody’s going to raise their hand for that.”

The Ontario government appears to recognize this problem, expanding and creating 18 new primary care teams in the latest provincial budget, Varughese said. “It’s a great first start, but we need to expand that. I’d like to see it five, 10 times higher.”

Rethinking compensation

Provinces struggling to fill family medicine residency positions could also look to British Columbia, which had the fewest vacancies, for different approaches to physician compensation.

In February, B.C. introduced a new longitudinal payment model that compensates family physicians based on the number of patients they see in a day, the size and complexity of their patient panel, and the time they spend on both direct clinical care and administrative tasks such as reviewing lab results or updating patient records.

“Nobody likes complete uncertainty when it comes to pay,” Varughese said. “What B.C. introduced was certainty. Having the ability to know what sort of income you’re going to have lets you take a breath.”

Political climate a factor?

Others cite the political climates in the provinces with the most family medicine residency vacancies as another factor driving trainees away.

Quebec has seen primary care fallout from unpopular health care reforms in recent years. However, the province has also increased the overall number of family medicine residency positions. Meanwhile, health minister Christian Dubé’s office attributes the residency mismatch partly to the pandemic, which has limited trainees’ exposure to family medicine during medical school practicums.

In Alberta, the number of family medicine vacancies after the first iteration of the match has been climbing steadily, from 11 under the New Democrats in 2019 to 42 under the United Conservative Party (UCP) this year.

“This is a huge red flag for the sustainability and viability of family medicine in Alberta,” tweeted Liana Hwang, an Alberta-based family physician working in refugee health and obstetrics.

Some physicians point to UCP hostility as a factor in declining interest in family medicine residencies in the province.

Under former leader Jason Kenney, the UCP tore up Alberta’s master agreement with doctors in 2019 and imposed a new contract without consultation, prompting the Alberta Medical Association (AMA) to file a $255-million lawsuit against the province. The AMA later dropped the suit when the government repealed its power to terminate or replace physician compensation agreements at will.

Kenney’s successor, Danielle Smith, has likewise proven controversial, starting her premiership by scrapping the Alberta Health Services board and firing Alberta’s chief medical officer of health.

“Alarming, but not surprising, that bright young medical students do not want to train or practise in Alberta under this government,” tweeted Tehseen Ladha, an Edmonton-based pediatrician and assistant professor at the University of Alberta.

Looking toward solutions

AMA president Fredrykka Rinaldi told CMAJ the growing number of family medicine residency vacancies after the first iteration of the match is “very concerning.”

“We are not competing well, and years of uncertainty and strain on primary care in this province have been a disincentive to learners looking for a place to train,” Rinaldi said.

Noel DaCunha, president of the Alberta College of Family Physicians, said family medicine is becoming “increasingly complex, and seemingly undervalued, we think more so in Alberta’s health system.”

DaCunha said significant system transformation is needed, but he is optimistic about proposed investments to modernize primary health care.

“We strongly believe in working with health care partners in comprehensive teams in supported environments that attract the best physicians and other primary care providers.”

Todd Anderson, dean of the Cumming School of Medicine at the University of Calgary, said B.C.’s new compensation model is one to watch.

If the province remains an outlier with almost no empty family medicine residency spots in years to come, Anderson said, “then that would be something I think the other provinces have to take into consideration.”

In the meantime, the University of Calgary is increasing the number of placements for international medical graduates and developing an admission pathway for students interested in primary care, exploring a model Philpott implemented at Queen’s where graduates can skip the match process and go straight into family medicine.

The University of Calgary is also using a new medical school curriculum this year that is more generalist-taught and patient-centric.

“What we want to do is have more role models for primary care,” explained Anderson. “Students will choose specialties where they see role models, and right now, we have a curriculum that’s taught by specialists.”