Did practice pathway fuel shortage?
Route to becoming a family doctor used to be a lot more straightforward
Ask George Ferrier, 76, why we don’t have enough family doctors today and he may snort in derision.
When he graduated medical school in 1973, all a new doc needed for a licence was a medical degree and a year of clinical training — basically, rotating internships in “medicine, surgery, pediatrics, and obstetrics,” he says.
That accomplished two things, says Ferrier.
First, a lot of physicians started as general practitioners. For example, 70 of the 90 members of his Dalhousie University graduating class began their careers as GPS, he says. That led to a good supply of GPS in the community, including him. Eventually, 30 of those 70 switched to specialties.
Second, young doctors had more time to decide what role in medicine best suited them because it wasn’t difficult to switch to a specialty later. That, he says, led to physicians making more informed choices.
That all changed in the early 1990s, Ferrier says.
LICENSING CHANGE
Following pressure from the College of Family Physicians of Canada and Upper Canadian medical schools, family medicine became its own specialty. Obtaining a licence the old way was no longer possible. You had to complete a two-year family medicine residency to get licensed. Switching specialties became more difficult, he says.
That’s when family medicine began to lose its appeal to young medical students, Ferrier says.
“All of the people who are involved in health care know that it was a huge mistake,” he says. “But no one is willing to deal with it.”
Ferrier, now retired from practice, is a former executive of the Medical Society of Nova Scotia, the forerunner to Doctors Nova Scotia. He’s now in his 10th year tutoring first-year Dal medical students.
He’s not the first physician who’s made this argument to me. From time to time, after I’d written on the physician shortage, someone would tell me the route to becoming a family doctor used to be a lot more straightforward.
COMPETITIVE SYSTEM
Today, medical graduates must enter the Canadian Resident Matching Service (CARMS) to qualify for a residency program. It’s an incredibly competitive system in which a computer algorithm matches would-be doctors’ preferences for specialty training with schools’ ranking of applicants.
For a med school grad, it’s vital to get accepted into residency, otherwise, there’s no pathway to a licence.
Yet, in the last five years across Canada, 117 out of 871 residency slots for family medicine have remained unfilled (though only one at Dal).
Although technically possible to switch residency programs, in practice it’s hard to do, says Daniel Bonner, communications manager (and not a doctor) for Maritime Resident Doctors, which represents about 550 medical residents training in the Maritimes.
Dr. Ferrier calls the CARMS system “a disgrace.”
New graduated medical students are forced to make career-defining choices after, perhaps, having taken just one course in the field, says Ferrier.
“It’s very, very, very stressful on the students, especially because it’s so competitive. And they’re not really sure, a lot of them. Can you imagine the student who’s never been through some of the fields that they might think they want to do? Some of them are actually applying to programs that they are hoping that is the right pick for them, but they don’t know for sure, they’ve never done some of them.”
Ferrier says that pressure is compounded because becoming a GP and later switching to anesthesiology, as he did decades ago, is now almost impossible.
Which lessens the appeal of family medicine.
LONGER RESIDENCY
Given all that, you might be surprised to hear the College of Family Physicians of Canada plans to make family medicine a three-year residency program by 2027.
That would provide a further disincentive to entering family medicine, based on what he’s heard from residents, Bonner says.
Last spring, Bonner recalls, one family medicine resident completing their program told him: “You know, if I was coming in, and they said, ‘it’s three years,’ and it’s also three years to do the first step of your internal medicine, why would I choose family medicine?”
Even among new doctors who complete family medicine residencies, we know that many choose not to go into traditional family practices, among the biggest reasons being huge student debt loads combined with lower income expectations.
I asked Ferrier why the resistance to revisiting the way doctors are trained.
“Hubris, in capital letters,” he says. “The College of Family Physicians always viewed themselves as being … the guys to fight for the general practitioners. They didn’t want general practitioners to be thought of as less than specialists. So, they wanted to create a specialty called family medicine. And in so doing, they shot themselves in the foot and they’re totally unwilling to come off that high horse and say ‘We made a mistake.’”
He acknowledges it would take a lot of work, and a lot of co-operation among medical schools, licensing bodies, the CFPC and others, to turn back the clock.
“I’m a bit cynical now because I’ve been fighting this battle for so long” and gotten nowhere, Ferrier says.
Now, I’m not qualified to say whether reversing course on licensing family doctors makes sense. I do know this. We don’t have nearly enough of them. Right now, at least 116,000 Nova Scotians say they need a primary care provider.
Let’s keep an open mind about solutions, from wherever or whenever they come.