Two years is not enough

Graduate instruction will be advanced and intensive—the natural prolongation of the elective courses now coming into vogue.

A. Flexner, 1910¹

Medical education in North America has changed remarkably when we compare the practices of the past with those of today.^2–4 A growing body of knowledge, fueled by a triumvirate of funding, research, and profit, has caused a steady increase in the quantity and quality of scientific and clinical knowledge necessary to train physicians.^5–7 With increasing patient expectations, today’s medical graduates are expected to be far better prepared “out of the blocks” than their predecessors just a generation ago.⁷

With the advent of primary care reform in several provinces, better remuneration, and the recognition of family medicine as a specialty in its own right, the profession is now poised to entertain one of its original great debates: Should postgraduate training be 2 or 3 years?^8,9 Let there be no mistake; the time to reconsider this debate is now, as we are currently investing a great deal of energy in redefining family medicine (eg, CanMeds–Family Medicine and the evaluation objectives).¹⁰

We have been debating the optimal length of family medicine training since before the inauguration of family medicine programs in 1966. Back then, many championed a 3-year family medicine training program similar to that of our American counterparts, but politics and fiscal restraint—not curricular rigour and academic proof—dictated the decision.

The existence of a 2-year training program in Canada and a 3-year program in the United States begs the question—which is best, 2 years or 3? Evidence favouring a 2-year program includes the success of family medicine programs here in Canada, the success of “accelerated” residency programs in the United States, and the positive effects that 2-year programs have on medical student residency choices.^11–14 Canadian and US governments have argued that doctor shortages and the almost prohibitive cost of medical education additionally justify the need to have 2-year family medicine training programs.¹³

However, others cite the decreasing hours of clinical care owing to residency contract agreements as a reason to increase the length of training programs.^3,6 In Canada the argument becomes all the more relevant when one considers that some US programs are now debating whether they should increase their training to 4 years.^8,14–17 There is simply more for today’s physicians to learn.

Continued growth

Fortunately, medicine is a living profession with a wealth of history, and it is perhaps in studying that history that we will resolve this debate. In 1910, most medical schools in Canada required their applicants to have only their high school diplomas. Today most students have university degrees and complete 4 years of undergraduate medical training and a minimum of 2 years of postgraduate training.

While there are definite advantages to a “better-educated” family doctor population, the possibility that Parkinson’s law will come into play is great.¹⁶ Simply stated, family medicine would need to work diligently to ensure that the same material covered in a 2-year curriculum was not allowed to balloon to cover a 3-year period. A mandatory third year would have to allow for more elective study in such areas as dermatology, sports medicine, and rheumatology. As part of that year, family medicine residents should be expected to assist with running family medicine wards and family medicine units as junior staff, supervising the more junior residents and medical students working with them. The extra training would allow residents to spend time learning traditional and nontraditional (eg, colonoscopy and colposcopy) procedural skills not well covered in today’s programs.

And what of the “unintended” consequences? Perhaps we would see a decrease in the number of consultations for investigations and procedures that should be routine, thereby decreasing the costs for governments. And what of that argument about the loss of productivity when such programs are implemented? It would only be for 1 year, and although this first class would not be out practising independently after 2 years of residency, they would still be caring for Canadians. As for patients, they might benefit from shorter times to diagnosis and faster access to other specialists. With a continued focus on the importance of a balanced professional life, we might just offset any possible decrease in medical student interest caused by adding a third year.

Lessons of the past

In some ways, today’s realities mirror those of the past, and to deny today’s family medicine graduates a longer training program is to deny them the lessons of that past. Departments of family medicine must strive to produce physicians who more closely resemble master clinicians. Two years is not enough time—as the body of medical literature continues to increase, postgraduate training will necessarily need to expand, maintaining that intensity of knowledge acquisition that simply cannot be replicated without too many years of independent practice. Longer periods of training for family physicians are inevitable; they are the natural prolongation of the hunger for elective courses, third-year programs, fellowships, and rigorous continuing education activities now coming into vogue.