Why students don’t want to be family docs
When most medical students don’t want to be family doctors, that’s a problem.
And when, even among those who do choose family medicine for a residency, many med students don’t want to actually practise as a family physician, that’s a crisis.
Which, on all counts, is where we are today.
A few weeks ago, I spoke with a recently graduated family doctor — one who joined a traditional practice in Nova Scotia — about why so many of his peers were avoiding family medicine.
Fearing speaking out could complicate his life, he asked to remain anonymous.
Medical schools have definitely increased their focus on family medicine, he said. It was a hot topic among fellow students.
But the prestige of becoming a specialist still carries a certain cachet for many med students, he said.
Besides, they all knew — and how could they not? — that due to the widespread shortage of family physicians, burnout was a huge concern. They knew family doctors in jurisdictions like Nova Scotia didn’t feel they were being treated equitably by the health-care system. And they believed the predominant payment model — fee-forservice, where family doctors get paid per insured procedure — didn’t offer fair compensation.
Even for students who did residencies in family medicine, there was muted desire to become a traditional family doc.
“Most of my classmates have opted not to go into clinical family medicines,” the young doctor said. “Most of them have gone on to do emergency medicine, hospitalist medicine, some obstetrics.
“It’s less than a third to a quarter of us who actually are doing any type of clinical family medicine.”
Money’s one reason. Graduating family medicine residents often have hundreds of thousands of dollars in student debt. So, they want positions where they can maximize their income.
For example, a hospitalist is a family doctor who provides medical care within a hospital.
“It is considered a very cushy job that pays about $100,000 more per year than (being) a family doctor does,” the young physician said, “without any need for extra training.”
The appeal of family medicine may even get worse, he predicted.
‘DISINCENTIVE’
Last spring, the College of Family Physicians of Canada recommended family medicine residency be lengthened from two to three years. The CFPC wants the new requirements in place as early as 2027.
“I’m starting to hear, from family or from medical students, that they see that as a disincentive for going into family medicine,” he said.
It would mean making lower pay (in residency) for an extra year and, thus, likely incurring more debt.
“And, even then, family medicine pay is at the lower end of the scale, regardless of which path you choose (beyond family practice). So you’re gonna have less money to pay off the debts that you have from your education.”
The CFPC’S plan to lengthen residency training — driven by a need to expand the curriculum, it says — for family doctors is certainly controversial. The body representing rural physicians, for example, is concerned it could exacerbate current shortages. Provinces must still sign off on funding the change.
But perhaps the biggest disincentive to becoming a family doctor in practice in a province like Nova Scotia, the young physician said, is too many are still paid using feefor-service.
“The fee for service model is not popular with anybody practicing,” he said. “You don’t get paid for things like paperwork. You don’t get paid for the patient that takes you an extra 15 minutes because they’re a bit more complicated.”
That’s versus salary-based models, where doctors are paid for seeing a quota of patients.
The young physician said he’s seen family doctors paid by fee-for-service quitting their practices.
In Nova Scotia, family doctors get paid in different ways: some fee-for-service, some salary. That “creates some resentment between family doctors.”
The government seems to like fee-for-service, I said, because it incentivizes doctors to see more patients.
SPEED VERSUS QUALITY
“You’re not wrong,” the physician agreed. “If you incentivize somebody to see as many people as possible, you will see as many people as possible to get your paycheck. That doesn’t mean that the quality of health care they’re being provided is realistic.”
With billing in 15-minute increments, you do what you can in a quarter-hour appointment but that’s generally limited, he said.
“You could be seeing more patients, but it doesn’t mean that the care that you’re providing is as good as the person who could sometimes see who they need to spend a bit more time with in order to get the job done properly.”
It can also lead to inefficiency. Health issues that could have been dealt with all at once, just not in 15 minutes, are split into separate appointments. Sometimes, prescriptions get refilled just for a month, not a year, to generate more billable appointments, he said.
For medical students with other options, family medicine is often just not that attractive.
That’s a national problem. But health is a provincial jurisdiction. With the number of Nova Scotians without a family doctor still rising, the Houston government — which made fixing health care its main campaign plank — is under increasing pressure to find solutions.
The young physician said he’s seen family doctors paid by fee-forservice quitting their practices.