It’s about time: 3-year FM residency training

Australia, New Zealand, and Ireland offer 5-year family medicine (FM) residency training. The UK is recommending moving to a 4- and eventually 5-year program on top of a 2-year foundational program.¹ All European countries train FM residents longer than 3 years. When the US soon moves from a 3- to a 4-year residency, Canada will have the shortest program in the world by a full 2 years. What do our international colleagues understand about the optimal length of training that we do not?

Debate about the length and scope of FM residency is not new.^2–9 Indeed, our FM residency started as a 3-year program in 1966, but was reduced to 2 years in the 1970s owing to funding concerns. The literature has scant evidence for what constitutes adequate time for training.² So why re-open this conversation? Because while the length of training has remained the same since the 1970s, medicine, family practice, and the health care needs of our patients have not. Canada is not the same in 2012 as it was in 1972 or even 1992. A culturally mixed, aging population with multiple chronic comorbidities and complex needs, an evolution to interprofessional care, nonphysician providers’ claims that they can adequately provide most care currently delivered in ambulatory settings, increasing social disparity, technological innovation, exploding medical knowledge and primary care research, new public health issues, recent restrictions on residency training hours, and a huge shift of medical care from hospitals to communities are but a few of the challenges faced by our FM residencies.

It is to our 2-year programs’ credit that, despite these challenges, graduating FPs provide excellent care to Canadians. But there are problems. Fewer FPs are providing full-scope, comprehensive care. More graduates are opting for office-based practice only. Only 10.5% of FPs practise intrapartum obstetrics.¹⁰ Most are not performing procedures that were once frequent in family practice. Many are opting out of hospital or emergency care. Proportionally fewer practise in remote and rural areas. Only 42% provide care in the home, and of those younger than 35, only 30% do.¹⁰ About a third opt for restricted or focused practices.

Many factors contribute, but it is likely that Canada’s current 2-year residency is too short to adequately enable residents to feel confident and achieve the many high-level competencies required to practise FM today. There just is not enough time to learn it all—especially the “out-of-office” or “harder-to-deliver” care described above. It is time to extend FM residency to at least 3 years so our residents can confidently practise full-scope, comprehensive FM safely and effectively anywhere in Canada.

As other providers seek increasing scopes of practice, and governments support their efforts, it is time for FPs to emphasize the secondary and tertiary competencies that distinguish us—especially the “harder-to-deliver” care FPs are leaving behind. Such care necessitates physician involvement and, owing to its complexity, logically requires more time to learn than it did 30 or 40 years ago.

As is now well known, the CFPC’s Triple C curriculum¹¹ is moving from time-based to competency-based training. The prediction is that most residents will achieve the current core competencies within 2 years.² In a Triple C world this is suggested as the minimum time required to develop confidence, competence, and professional identity. It is argued that it is not possible to determine the optimal length of training until each program has a competency-based, in-training assessment in place. This makes intuitive sense, but can we afford to wait 5 to 10 years to find out, while fewer FPs practise truly broad-scope care?

Triple C also does not address some of the shortcomings noted above in practising comprehensive care, which might be related to graduates’ competence and confidence. Some argue confidence is not a reason to lengthen training, but it is cited in other countries as a valid reason.¹

Approximately 23% of residents undertake a third-year enhanced-skills program; an additional 30% consider it.¹⁰ Thus perhaps 40% of residents will be training longer than 2 years anyway. Green et al showed that third-year training is strongly associated with increased care outside the office.¹² They suggest that longer training might help ensure more Canadian graduates practise comprehensive FM. A 3-year FM residency could well diminish the need for enhanced-skills training and the tendency to more focused practice.

Longer FM residency is not exclusive to competency-based education. Improved efficiency in teaching² will help in increasingly legislated time-restricted programs, but training longer than 2 years is needed to practise comprehensive FM in the 21st century. It really is about time.