Abstract
Background
Third-year enhanced skills programs, also known as family medicine (FM) PGY3 programs, have always been an area of debate. Their exponential growth does not stem from a strong body of academic evidence or public health needs assessment. This qualitative descriptive study explores the current perspectives of second-year FM residents at the University of Ottawa on extended training programs through semi-structured interviews.
Results
Of the fifteen participants, eight were applying to PGY3 FM programs, six were not and one was unsure. Themes generated included: developing generalist niches within primary care, increasing confidence of FM graduates, allowing generalists to fill in healthcare gaps to meet community needs, meeting the pressures of workplace competition and employability requirements, and creating alternate paths to five-year specialties. 80% would extend their core FM training, with self-design and options of shorter time frames as preconditions.
Conclusion
FM residents are interested in furthering their training, whether through extending core residency period or via enhanced skills programs. The demand for these programs will continue rising. Capitalizing on residents’ interests to catapult the profession forward and optimize the quality of healthcare should be the priority for licensing bodies and medical educators.
Abstract
Contexte
Les programmes de compétences avancées de troisième année, également appelés programmes R3 en médecine familiale (MF), ont toujours fait l’objet de débats. Leur croissance exponentielle ne découle pas de preuves scientifiques solides ni d’une évaluation des besoins en santé publique. Cette étude qualitative descriptive explore par le biais d’entretiens semi-structurés les points de vue des résidents de deuxième année en médecine familiale de l’Université d’Ottawa sur les programmes de compétences avancées.
Résultats
Des quinze participants, huit postulaient à des programmes de troisième année MF, six ne le faisaient pas et un était indécis. Les thèmes suivants ont été abordés : développer des créneaux généralistes au sein des soins primaires, accroître la confiance des diplômés en médecine familiale, permettre aux généralistes de combler les lacunes en matière de soins de santé afin de répondre aux besoins de la communauté, répondre aux pressions de la concurrence en milieu de travail et aux exigences en matière d’employabilité, et créer des alternatives aux programmes d’autres spécialités d’une durée de 5 ans. Quatre-vingts pour cent des participants prolongeraient leur formation de base en MF, à condition de pouvoir la concevoir sur mesure et d’avoir la possibilité de formations de plus courte durée.
Conclusion
Les résidents en MF sont motivés à poursuivre leur formation, que ce soit en prolongeant la période de résidence de base ou par le biais de programmes de compétences avancées. La demande de ces programmes va continuer à augmenter. Les organismes de certification et les enseignants en médecine devraient reconnaître comme une priorité la possibilité de tirer profit de l’ambition des résidents de faire progresser la profession et d’optimiser la qualité des soins de santé.
Introduction
Third-year enhanced skills programs, also known as family medicine (FM) PGY3 programs, have grown considerably since their establishment in the 1980s.1 The 1984 Canadian Medical Task Force Association Task Force on Education for the Provision of Primary Care Services advocated for “sufficient extra residency training positions be funded to allow some family physicians to develop areas of special competence.”2 In 1989, 66 positions were offered at 10 FM programs across Canada.3 In contrast, Slade et al. identified a total of 126 PGY3 FM programs listed across all 17 Canadian medical schools in 2015, with 736 PGY3 FM graduates in the 2011-2013 exit cohorts. Extended programs fall under two categories: Category 1, such as emergency medicine, anesthesia, and palliative care, have national accreditation standards. Category 2 programs, such as women’s health, hospitalist medicine and global health, have locally determined curricula.4,5 Data from the Canadian Post-MD Education Registry shows that the proportion of Family Medicine graduates pursuing training after core residency training rose from 10.9% in 1995 to 21.1% in 2013, with Queens University having a third (35%) of its 2011-2013 graduates pursue PGY3 FM training.6
Surprisingly, this substantial increase in resident interest and PGY3 FM program positions does not seem to stem from a strong body of academic evidence or public health needs assessment. According to Green et al., there has been no “defining document describing the policy development, design, and implementation of the family medicine PGY3 programs.”1 In their 2009 study, Green et al. reported that the pursuit of increased confidence, competence, higher remuneration and employability were key factors behind increased interest in the PGY3 program and that resident factors, rather than community needs, drove the demand for extended training.1
Despite the absence of a defining policy governing enhanced skills family medicine training, training statistics suggest that this rise in enhanced skills training programs is expected to continue.1 In 2011, the College of Family Physicians of Canada (CFPC) approved the launch of the new Triple C curriculum on the basis of ensuring “all FM graduates are equipped with competencies that respond to the changing health care needs of Canadians.”7 In 2017, CFPC updated its CanMEDS-FM competency framework of the roles and responsibilities of Canadian FM graduates.8 The evolving Triple C curriculum, updated CanMEDS-FM, and the rise of PGY3 FM program training have led Slade et al. to describe this time as a one of “substantial pedagogic change,” whereby the future of family medicine as a specialty is being redefined.6 This gives rise to an important question: why is an increasing number of family medicine residents choosing to pursue enhanced skills training?
The objectives of this study were to explore perceptions of FM residents of the rising PGY3 programs and to gain insight on their views regarding enhanced skills training in family medicine.
Methods
Design
We employed qualitative description as an approach for our study.9 We chose this approach as we wanted to understand the residents’ perspective regarding these programs. Our methods employed semi-structured interviews; this allowed for in-depth exploration and analysis. A list of questions and prompts, based on a literature review of the topic, guided the interviews.
Statement of Ethics
Ethics approval was given by Ottawa Health Science Network Research Ethic Board (OHRI) and Bruyère Continuing Care Research Ethics Board.
Participants
We invited FM residents (2018 exit cohort) from all training sites at the University of Ottawa via email (August 2017) and with an on-site announcement (October 2017) to participate in the study. A total of 15 residents were recruited using a purposeful sample approach aiming to interview a representative sample of residents from all of the university’s training sites. (Table 1) We held the interviews at the Elizabeth Bruyère Hospital in Ottawa.
Table 1.
Participant distribution
| Factor | % (n) |
|---|---|
| Training Site | |
| Academic (Anglophone urban sites) | 40% (6) |
| Community (Anglophone urban sites) | 20% (3) |
| Montfort (Francophone urban hospital) | 27% (4) |
| Rural | 13% (2) |
| Sex | |
| Male | 33% (5) |
| Female | 67% (10) |
| Medical Graduates | |
| Canadian Medical Graduates (CMG) 67 | 87% (13) |
| International Medical Graduates (IMG) 7 | 13% (2) |
| PGY3 Program Consideration | |
| Applying/ Considering Application to PGY3 | 53% (8) |
| Not applying to PGY3 | 40% (6) |
| Unsure | 7% (1) |
Data Extraction
EA, known to the participants as a classmate and peer, with no position of authority or influence, transcribed and conducted the interviews; transcriptions were de-identified as to maintain the anonymity of participants to the rest of the research team. Using the constant comparative method, EA reviewed transcriptions and identified underlying patterns and themes; this method allows for data to be concurrently collected and analyzed, thus informing subsequent data collection.10 Accordingly, conceptual codes generated were analyzed allowing for the thematic categories to be refined further.11 By the thirteenth interview, theoretical saturation was attained. This process of data analysis and open coding generated common themes relating to reasons motivating residents to pursue PGY3 programs after FM certification.
Independently, DA (medical education researcher at the University of Ottawa) and ES (Program Director of the Enhanced Skills Training Program at the University of Ottawa at the time of the study) thematically analyzed a random selection of transcriptions, comparing and refining the codes generated by EA. The codes were agreed upon following a group discussion between the members of the research team.
Results
Emerging themes
With the data collected from the interviews, we developed five emerging themes. Quotes from each of the five themes can be found in Appendix A.
Theme one – “A Generalist’s Niche”
Most participants attributed their pursuit of FM to its broad scope of practice, flexibility, lifestyle, and geographic portability; code words such as “diversity” or “variety” emerged in 14 interviews. Nonetheless, many interviewees attributed the rise of the generalist “niche” phenomenon to personal interests, ever-broadening scope of medical knowledge, rising demands of primary care, mounting competition in the workforce, and financial benefits of offering focused care. Six participants perceived focused practices as having negative implications on the broad and comprehensive scope of FM.
Theme two – “Confidence of Family Medicine trainees”
Thirteen participants explained that the desire for confidence and competence is driving an increasing number of FM residents to prolong their training. Over half of the participants attributed this to the short duration of FM training in Canada.
Theme three – “Generalists filling healthcare gaps”
Participants attributed the trend of PGY3 programs to the demands of our healthcare system and the increasing burden and responsibility of family doctors to cover a wider scope of practice. In line with this, thirteen of the fifteen participants would allow family doctors to assess the needs of their communities and return to train in focused areas to improve patient care. Indeed, most participants echoed that community needs should determine resource allocation and training programs, not resident merit and interest. In comparison, one participant was opposed to increasing options for re-entry practice, and one participant was unsure.
Theme four – “Pressure of further training”
Workplace competition and employability requirements were reported as factors contributing to the pressure of considering extended training: these credentials are sometimes required for employment and academic appointments. Five participants were concerned with the rise of PGY3-trained family physicians diminishing the value of core FM degrees.
Theme five – “Alternate path to Royal College specialties”
Six participants raised the possibility of family medicine being used as an alternative path by residents to a CaRMS five-year specialty match, a misuse of educational resources, as those trainees do not intend on becoming primary care providers.
Finally, if given the option, 80% of participants would extend their training in core FM training program with self-design and shorter timeframes (from a minimum of three to a maximum of 12 months) as preconditions.
Discussion
Research supports that the demand for skill-enhanced programs will continue to rise. 5 Reasons behind this movement towards generalists with special interests are multifactorial and encompass personal interests, career goals, employability, increasing confidence and competence, and meeting community needs. Analysis of the interview transcriptions and emerging themes gave rise to the following follow-up questions:
Are PGY3 FM programs a threat to comprehensive Family Medicine?
Most participants valued the fundamentals of FM, such as comprehensive and longitudinal patient relationships, and seemed keen on maintaining those in their practice. Participants did not deem the rise in PGY3 program interest as a threat to the field of comprehensive and generalized FM. This aligns with current data on practice patterns of PGY3 FM graduates, which shows that concerns of “quasi-specialized” family practitioners are unfounded;12 especially since the need for family doctors with focused skillsets reflecting demands of Canadian communities is well-established.13
To better assess the implication of a continued rise in PGY3 programs, an analysis of the current landscape of family practice is necessary. In the 2013 Canadian National Physicians Survey, 68% of family physicians identified an area of focused practice.14 It is unlikely that all physicians were PGY3 FM graduates, and probable that they developed an area of special interest through continued education and/or self-directed learning. Consequently, this rise of PGY3 FM programs in Canada could be a reflection of the current climate of general practice with areas of focused practice.
Length of training: is two years enough?
Participants alluded to the briefness of FM residency training in Canada as a motivating factor behind the pursuit of PGY3 programs; a majority of participants would either a) pursue a PGY3 program or b) extend their core program if there were no application process and if curriculums were self-designed to fill in knowledge gaps and meet personal development goals. This reflects a CFPC working group’s suggestions that program length should allow flexibility for implementation of competency-based medical education, perhaps closing the gap in training between the generalist and the specialist identified by the 1984 Canadian Medical Task Force Association Task Force on Education for the Provision of Primary Care Services, which stated “given the professional goals we have assumed for the family physician, we cannot defend the disparity of training efforts expended on the generalist and the specialist. Either the generalist is under-trained or the specialist is over-trained.”15 This then brings us back to the core question of “How long does it take to train a competent family doctor?16 A question that is being revisited by the CFPC, with Lemire and Fowler reporting that the “status quo is no longer an option.”17
Are you “just” a core family medicine graduate?
Participants were frustrated by the possibility that core FM graduates who choose not to pursue a PGY3 program would be looked down upon or become disadvantaged as more family doctors now have additional qualifications. The CFPC will need to clarify the value of the core FM degree now that more graduates lengthen their training.
Is it up to family medicine alone to fill in the gaps of our healthcare system?
A participant asked if it is the role of family physicians to fill in the gaps of our strained healthcare system, raising questions surrounding equipping and supporting first-line generalists as they strive to meet patient and community needs.
Limitations
Restrictions and purposeful sampling of participants may have increased biases; residents interested in this discussion were probably more inclined to participate in our study. As a result, the data collected might not reflect the general resident population across the University of Ottawa. Co-authors EA (FM resident matched to a PGY3 program) and ES (Program Director for Enhanced Skills PGY3 programs at the University of Ottawa at the time of the study) may have potential biases and favourable views of the PGY3 FM programs.
Conclusion
FM residents demonstrate an interest in furthering their training, whether through extending their core FM training period or applying to Enhanced Skills programs. The drivers include gaining confidence and competence, exploring personal interests, and meeting community needs. As such, medical educators and certifying bodies should harness those interests and channel them strategically and thoughtfully to catapult primary care forward and optimize the quality of comprehensive healthcare in Canada.
Acknowledgements
The authors wish to thank the residents who participated in the study.
Appendix A
Resident Quotes from Thematic Analysis
Theme 1: A Generalist’s Niche
Resident A: “I think people realize once they are in family medicine how hard it actually is to know everything… so they like the idea of having one area where they are an “expert”.
Resident B: “This [PGY3 training] makes practice a little easier because family medicine is going to be such a big, big large topic and often people are finding they might be more comfortable doing certain subsets that they are interested in.”
Resident C: “More and more is falling on family medicine. This [PGY3 training] allows us to draw on each other’s extra training…it gives us a little bit of offloading of this huge scope that we feel we have to take on.”
Resident C: “Family physicians are well-suited to have niche areas. I think it is very possible to have a general practice… and to pair that with a special interest… That allows us to pursue those specific passions within the scope of family medicine that make us a little bit more of an expert on a topic that satisfies us academically and personally and allows us to be resources for other physicians who can’t, don’t have time or prefer not to develop those special interests.”
Resident D: “It’s a lot of the competitiveness of desirable positions in desirable locations”.
Resident E: “I think probably the current climate, when we look at working in just family medicine right now, that’s scary with everything that is going on politically, as far as like salaries go and things like that. So, it has sort of that added appeal… I’ll have this added skill that will make me a little more essential.”
Theme 2: Confidence of Family Medicine trainees
Resident D: “An extra year of paid learning and supervision is definitely an advantage. You can develop your skills and gain experience both in your specific field and more generally… while still having the protection of being a trainee.”
Resident F: “There is also the piece, I think, where a lot of graduates do not feel ready at the end of their 2-year training program.”
Resident B: “… Having close contacts having done family medicine in the US where it is a 3-year program. Seeing the difference it has made in their practice as they exited and in their comfort and competency in having that extra year. Partly because the extra year was used to essentially go to smaller subspecialty clinics, supervise other residents, function as mini-staff or seniors… they really consolidated all the information that they had.”
Resident G: “I think if a lot of people were doing a PGY3, I don’t know what percentage are, but if a really high percentage were, then I think it kind of leaves the impression that most people don’t feel like the 2-year program is sufficient to train you to be a family doctor. So kind of looking back or from the outside, it might look like there shouldn’t even be a two year program, it should be a 3-year program.”
Theme 3: Generalists filling healthcare gaps
Resident C: “One of the issues I see in family medicine is the scope is huge and we know that coming in. But I feel like the scope is ever broadening because there are just more and more things falling to family medicine because specialist wait times are backed up.”
Resident H: “When I’ve been in rural environments, people that have had a PGY3 have been like a consult service for other family doctors who didn’t get the extra year of training.”
Resident E: “But I do think, you know, we have lots of communities that are underserved, but you can’t force Family Medicine to service every underserved community. Why can’t emergency trained or internal medicine trained go work in these areas too?”
Theme 4: Pressure of Further Training
Resident A: “It probably negatively affects the worth of a 2-year program. Like not right now, but I think long term that can definitely happen. They’ll be like “oh did you do a +1? Oh, just the 2 years?” It’s like people look down on you if you hadn’t done a +1.”
Resident I: “There is sometimes a lot of pressure put on people to do an extra year of training. I hear a lot of people say “Oh, are you doing a PGY3?” and seem like they expect you to be doing one.”
Resident J: “I think in the future, if the demand for family doctors were to lower then it could be that just having a 2-year training would be disadvantaged compared to PGY3s.”
Theme 5: Alternate path to Royal College specialties
Resident A: “I think everyone goes into family medicine originally thinking like I’m going to apply to a +1… People are kind of using it as like a springboard into that practice – so they’re kind of skipping the line. So people who are applying to the ER +1 and they’re doing the FM training - did they ever really want to do family medicine or was this their plan all along? I think that’s a disadvantage to having the program.”
Resident H: “The disadvantage that I see is that there are some people that apply to family medicine just to do the PGY3, which kind of draws away from family medicine as a whole in my opinion.”
Resident G: “I think family should still be promoted as a specialty, not as a 2-year program you can use to short cut to other goals.”
Resident K: “Some family medicine residents wanted specialties to begin with so they are kind of going into the subspecialty to do what they initially wanted.”
Conflicts of Interest
We acknowledge no conflicts of interest due to financial and personal relationships that my bias our work.
Funding
No funding was received to support this work.
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