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To the editor:
It’s funny that six year later, I have been afforded a new opportunity to engage again on the topic of whether base family medicine residency in Canada should be extended to three years. I recall responding to Dr. Buchman’s original article in Canadian Family Physician on the topic in 2012. (1) Many of the issues that led me to disagree with a three-year family medicine residency remain salient or even more convincing today.
In the intervening time since 2012, current cohorts of family medicine residents are graduating with even more historic debt loads, and are also graduating even older, due to the four-year undergraduate degree entry requirement and unprecedented levels of competition that see many complete a graduate degree prior to or during medical training. This means that an extra year weighs that much more heavily in financial and family planning – and likely would also impact the desirability of family medicine as a potential specialty choice.
Additionally, as in 2012, the concern expressed by Dr. Buchman that family doctors are restricting their practices or not providing various aspects of care may well be explained by other factors besides training length and exposure. Home care, cited in the article, is a great example—typically not well remunerated, resource intensive, and with significant impacts on work-life balance; an extra year of training simply will not address these disincentives to providing full-scope care.
Finally, the expectation that any residency helps trainees “get it all” in any amount of time is regrettably unrealistic. Perhaps this relates to my own experience concurrently training in public health and preventive medicine, where no amount of training would allow anyone to “get it all” during five years of residency. Related is the idea that most educators support a move away from “steeping tea” and more towards competency-based education. Rather than simply putting people on a conveyor-belt prescribed program and expecting success from completing a set amount of time filled with various disparate experiences, educators need to be focused on competency as the ultimate outcome. This means working to foster approaches and critical thinking skills that will allow future physicians versatility and the ability to flourish in just about any situation or context.
This means setting training up to give skills to young docs that will start them on their practice journey and explore areas like home care as they grow their career, rather than fancifully imagining that a mandatory month long rotation on home care equals competence. One only needs to look at mandatory rural rotations to see how successful that has been in achieving its stated goal of encourage more physicians to practice in rural settings.
That brings round the final point – in response to the question "what do other countries know that we don’t know?" The most obvious answer to this question is its null hypothesis: there may very well not be anything. Firstly, there is an easy way to find out – get comparative data on family physician competence specifically, rather than using “primary care systems” as a poor proxy – the differences in the system may very well not have anything to do with training, but everything to do with how the system is funded or organized. Secondly, which recalls my conclusion from six years ago: one wonders what is wrong with family physicians in Canada and how they measure up to family physicians in the other countries cited. Is family medicine in Canada in crisis? Are the vast majority of our two-year graduated woefully undertrained? Are we regularly seeing significant practice mishaps on what would be considered core learning?
I think the answer is fairly obvious – we have some of the best trained family physicians in the world.
Simply put, there is no guarantee that the concerns raised by the proponents of longer training in the article will be addressed by lengthening training time—and everything to suggest that doing so will reduce the desirability of family medicine as a specialty, impose significant burdens on our future family physicians, and largely fail at getting to what should be the basis of training: competence-building rather than exposure to an ever-growing sundry set of arbitrary experiences and a longer time spent on service.
(1) Loh LC. It's more than "just" a year. Can Fam Physician. 2012 Dec;58(12):1332-4.