Response to Lavergne et al

In reflecting on this month’s Canadian Family Physician article entitled “Changes in comprehensiveness of services delivered by Canadian family physicians. Analysis of population-based linked data in 4 provinces”¹ and the related commentary entitled “Ending the generational blame game. Let us move forward with needed primary care change,”² we note that the authors bring much-needed expertise to the study of comprehensive family medicine care. However, they have presented interpretations and characterization of the College of Family Physicians of Canada’s (CFPC’s) view of early career family physicians that are, regretfully, unsupported and inaccurate.

The CFPC’s definition of and emphasis on comprehensiveness in residency training arises from the need to nurture this important and evidence-based feature of generalist practice. It must be emphatically stated that there is no part of the CFPC’s analysis or recommendation that seeks to target or blame younger generations. To the contrary, the CFPC recognizes that family physicians face a multitude of barriers to and constraints in providing broad-scope, generalist care. It is for the College to ensure that education is not a barrier and that every resident has the opportunity to train to the full scope of the discipline, defined by the Residency Training Profile,³ to enable greater opportunity, community adaptability, and practice mobility for our graduates. Positioning comprehensiveness as a priority for training is consistent with supporting the role of family physicians in a dynamic and increasingly complex health care system. This important commitment to learners, educators, family physicians, and communities bears reinforcing, as it was regrettably omitted from the commentary by Lavergne and colleagues.²

As correctly observed by the authors, insights from the study of comprehensive family practice remain crucial to this period of family medicine education renewal. However, we would also note the need for broader health system change to support family medicine, which is under way in small measure, such as in British Columbia, where primary care has been the focus of new and needed investment.⁴ Robust, multifactorial research remains important to evaluating how changes in health policy and educational curriculum support family practices.

A key strength of the study method of Lavergne et al is that it yields data related to family physicians’ service settings and service areas.¹ This method is novel and sheds light not only on the types of services family physicians provide, but also where they provide them. The authors observe that declines in comprehensive practice “are largely related to a decrease in the number of service settings in which family physicians are working, rather than physicians restricting service areas in office-based care.”¹ This nuanced finding can indeed help support the arguments for both health system and education reform.

The authors also assert that the “narrowing of comprehensiveness … [is] more likely related to the practice context overall and not training experiences.”¹ The CFPC agrees that current conditions of practice are a major driver but advances the view that education also plays an important role. In fact it does not appear that the authors’ methods and findings identify the importance of training as an instrument to bolster comprehensive practice by family physicians and, thus, they leave their assertion unsupported. By design, the study relies on family physician billing data at 2 points in time: 1999 to 2000 and 2017 to 2018. We agree with the authors’ noted limitations about billing data, but also assert that the early career family physicians of 1999 to 2000 are prominent among and may account for most of the later-career family physicians of 2017 to 2018.

This design means, effectively, that the study measures a single group of family physicians at 2 different time points—and furthermore that neither the study design nor the data enable an exploration of possible educational influencers, such as the rotating internship and Triple C curriculum, both of which are contemporaneous with the study period. Thus, while the study findings are informative, they do not appear to be focused or strong enough to support assertions about the role of training in shaping the practice of future family physicians.

In fact, studies old and new show that family medicine training does shape family physicians’ future practice scope. In the context of enhanced skills training, Chan wrote in 2002 that “physicians with a CCFP-EM were more likely to practise emergency and inpatient medicine.”⁵ In a qualitative study 2 decades later, Kabir et al wrote that “participant groups reported training experiences that increased their comfort with focused areas of practice.”⁶ An evidence summary of the CFPC’s Family Medicine Longitudinal Survey (FMLS) shows strong associations between residents’ training experiences, their sense of preparedness, and intentions to perform clinical procedures and to practise in office and hospital-based settings.⁷ A further FMLS analysis shows a high correlation between second-year family medicine residents’ intended future practice areas and their actual areas of practice 3 years after completing residency training.⁸ There is strong evidence that education shapes practice. To lose sight of this is to jeopardize an intentional and important way in which family physicians can be supported to meet the comprehensive health care needs of society; that is, through education and training.

The CFPC focuses on educational influences because we have a duty to do so within the broader health care system. We would be remiss in this duty if we did not respond to learners’ needs, as expressed by learners and practising family physicians. Across multiple domains—such as primary care, emergency care, hospital inpatient care, advocacy, and scholarship—early career family physicians have indicated that their training prepares them for some professional activities but not others.⁹ Ongoing results of the CFPC FMLS show that the most second-year family medicine residents believe they have had good exposure in areas like mental health, chronic disease management, and providing care across the life cycle. However, many have identified limited exposure to intrapartum care (16%), palliative care (17%), office-based clinical procedures (19%), practice in long-term care homes (38%), in-hospital clinical procedures (58%), and care for Indigenous populations (38%).¹⁰ The CFPC honours above all else its members and family medicine educational leaders who take it upon themselves to serve the comprehensive care needs of patients and communities. Our commitment is to help them achieve that end through evidence-based, supportive health policy and training.

Family medicine training nurtures a highly adaptable family physician workforce that serves society while giving family physicians the latitude to shape their future careers. Some family physicians will practise within many domains covered during their residency programs. Others will focus on a subset of family medicine activities. Medical regulators require all physicians to practice within their scope of training, and broad cognitive and experiential learning enables family physicians to meet regulatory requirements. At the same time, however, training enables family physicians to adapt their practice in ways that respond to changing societal needs and to pursue avenues of practice that bring professional satisfaction.

The CFPC acknowledges that education reform will have impacts on today’s learners and educators but is convinced of the longer-term benefits that this will provide in improving training outcomes and driving changes in the practice environment by supporting advocacy efforts. We disagree categorically with any suggestion that reform efforts are an exercise in targeting or blaming any generation; doing so sows seeds of division and creates opposition where none need exist. We would posit, in fact, that our shared aim—in time and in collaboration—is to empower and support all family physicians now and in the future. To understate the importance of residency training is to risk constraining family practice and, ultimately, to jeopardize the broad service and scope of care that family physicians collectively contribute throughout the health care system.

Lavergne et al ask us to “consider changing the health system and service delivery contexts in which all physicians are practising.”¹ We wholly agree. The health system fails to capitalize on the investment that goes into training a highly adaptable family physician workforce if it erects barriers to comprehensive family practice. The CFPC is leading the charge in advocating for health system change that embraces the Patient’s Medical Home, a fully integrated model of care that best serves patients and health care workers alike. It is important that we continue to study the impacts of specific health system changes, followed by action that leads to positive outcomes and mitigates negative ones. We see a multipronged strategy that couples health system and educational reform as necessary for the betterment of practice contexts, comprehensiveness in family medicine, and societal health.

We thank the authors for their scholarship and commitment to family medicine and primary care. As in our past collaborations and engagements with the authors, among other collaborators, we hope for a full and open sharing of knowledge and perspectives. We believe our aims are convergent. Together, and through coordinated effort, we have a greater chance of effecting multipronged change in the service of patients, communities, and family physicians.