Sunday, April 7, 2013

Family Medicine in Canada

By: Dahlia Balaban BSc, MSc (future MD as of June 2013 and Future Family Medicine resident as of July 2013)

As a first and second year medical student, I never thought I’d go into Family Medicine-- I always saw myself as someone who loves the busy hospital environment and thrives under pressure. Further, all my mentors were internists who seemed to know everything there was to know about physiology, pathophysiology, and treatments.

My career plans began to change during my third year, when I made my hospital debut and found a Family Physician mentor who inspired me to change my perspective. I quickly realized that it’s the patients and the continuity of care that appeal to me most about medicine. I started to appreciate that I’m a generalist who likes everything, and there’s nothing in medicine that I would give up in order to specialize in any one area. It also occurred to me that good Family Physicians have the potential to be the most influential health care providers for their patients, since they are involved in primary, secondary, and tertiary prevention. They have the ability to keep their patients healthy, treat them when they’re sick, and prevent them from getting re-admitted to hospital after discharge. Most importantly, they are professional advocates who help their patients digest health-related information and navigate the healthcare system.

Family Medicine has long been a popular career path for medical students in Canada. Over the last few years, 30-35% of students graduating from Canadian Medical schools chose Family Medicine as their first-choice discipline. In 2012, McGill had the smallest percentage of its graduates choosing Family Medicine (24.7%) while the Northern Ontario School of Medicine, which was originally created to help produce primary care physicians to work in under-serviced areas, had 53.7% of its graduates choosing it. There are many reasons why Canadian medical graduates are drawn to family medicine, and I will outline some of them below.

Top 10 Reasons to Pursue Family Medicine Training in Canada (in no particular order):

1) Short, 2-year Training Program:

The College of Family Physicians of Canada (CCFP) was created in 1967, and Family Medicine officially became a Canadian “specialty” in 2007. Until the early 1990s, all medical school graduates in Canada did a one-year rotating internship after which they could practice as General Practitioners (GPs) or choose to pursue further specialization. Since then, Family Medicine training in Canada has been 2 years (it is the only post-graduate medical program that is shorter in Canada than in the US). Some have argued that 2 years is not enough for residents to gain the skills they need to practice effectively as Family Physicians, but the length of the program certainly makes it attractive for people who are looking to finish their training and start practicing as soon as possible (especially those who are worried about their loans or those who went to medical school later in life). In any case, many people argue that the most important learning in your career is not when you’re a resident, but when you are starting out on your own in practice.

Although the residency is short, all the Family Physicians I have spoken to who trained in Canada have told me that they transitioned well into practice once they finished residency. However, many of them mentioned that you never really feel ready, no matter how long you’ve trained and you need just need to put yourself out there and take the plunge because you always know more than you think you do.

In contrast to Family Medicine, all other residency training programs in Canada require anywhere between 4-6 years, including Pediatrics (minimum of 4 years to become a general Pediatrician), Internal Medicine (now requiring a minimum of 5 years, even to become a General Internist), and ER (the Royal College specialty requires 5 years of training). This means that Family Medicine training is at least 2 years shorter than any other training program in the country.

2) Salary:

Family Physicians in Canada work under a variety of remuneration models, from fee-for-service to capitation to capitation with shadow billing to salary (click for an example of this model in Ontario). No matter the model, Family Physician salaries in Canada are competitive with many other medical/non-surgical specialties (especially given the flexibility of the job and the short length of the training program). For example, on average, the gross fee-for service billings of Family Physicians in Canada is similar to that of Psychiatrists (5 year program), Neurologists (5 year program), Physiatrists (5 year program) and Pediatricians (4-5 year program). Information on gross physician billings in Canada is collected by CIHI in the National Physician Database.

3) Portable:

While many specialists in Canada struggle to find work after finishing their training (some needing to pursue multiple fellowships before they are able to find employment), Family Physicians are in demand all over the country, both in urban and rural settings. Residents often choose to locum for 1-2 years after finishing their training so they can try out different work environments and locations before deciding on where they want to permanently practice.

4) Flexible:

Family Physicians have the most flexibility in terms of how much to work, when to work, and how to work. Most Family Physicians now work in group practices that have daytime hours as well as evening and weekend hours, and they can decide amongst themselves how to divide the responsibilities. Sole practitioners generally have less flexibility, but they have the advantage of being their own bosses so they can take time off as they want. Lastly, it’s common in Family Medicine to do locums after finishing residency training, and these are great when Family Physicians want to go on vacation.

5) Many ways to practice:

Family Physicians can choose to practice traditional, office-based Family Medicine, but many choose to supplement traditional practice with other types of work in order to keep things interesting (so they’re not doing outpatient clinics 5-6 days a week). There is one board-certified Family Medicine Fellowship in ER (1 extra year) in addition to many other add-ons that are offered by the various residency programs. These add-ons vary in terms of training time from 3 months to 1 year. While these options are available, many Family Physicians can practice in each area without any further training beyond the 2 years, as long as they feel comfortable/competent and are able to find work. For example, Family Medicine residents can often get jobs working in Emergency Departments without any extra training once they finish residency. They can later challenge the ER fellowship exam after working for a certain amount of time so they can get the professional designation and have more employment opportunities.

Family Physicians can “sub-specialize” or practice in the following areas, with or without extra training (this is not an exhaustive list):

Breast Diseases
Care of the Elderly
Global Health
Indigenous Health
OB (low-risk)
Palliative Care
Sports Medicine
Surgical Assist
Travel Medicine
Women’s Health

How Family Physicians practice generally depends on the needs of the community in which they work, but Family Physicians are also portable enough to move around until they find a community in need of the services they want to offer.

6) Generalist, fast paced, diverse:

Primarily, Family Physicians are generalists. They are trained to see people of all ages, including the healthy and the sick. On any given day a Family Physician can see babies and elderly patients, do well patient visits, follow up visits for chronic health problems, and assess acute illness. They may do minor procedures and they may send a patient to the ER for a full assessment. They provide primary care to patients with weird and wonderful presentations. Family Physicians typically see 4-6 patients per hour so it appeals to those who like busy, fast-paced environments. Further, some Family Physicians have a general practice in addition to a more specialized practice or hospital work. They may have multiple ways they practice within the same day, within the same week, or within the same career. No matter what, there’s no shortage of options for Family Physicians.

7) Family Physicians are integral to the medical system in Canada:

For better or for worse, Family Physicians act as “gatekeepers” to all specialists in Canada. This means that patients almost always need a referral from a Family Physician (or ER doc) before they can see a Cardiologist, a GI specialist, or a surgeon (to name a few) on an outpatient basis. This means that there is always a lot of business for Family Physicians, and Family Physicians are able to follow all aspects of their patients’ care. 

8) Quality of residency programs

In Canada, all residency programs are tied to a university that also provides undergraduate medical education. There are a total of 17 of these in Canada (of which 3 are in Quebec and are exclusively Francophone). While each of these programs may have multiple training sites, either urban or rural, all sites are overseen by the main university and are held to very high standards. This means that all Family Medicine training sites are considered to be of comparable quality and boast high pass rates for the CCFP exam. You really can’t go wrong by attending any one of the 17 Family Medicine training programs, in any one of the available sites. Most residents end up choosing a program based on location, type of program (eg. urban vs. rural, block vs. horizontal curriculum), and unique aspects of the program (eg. Francophone vs. bilingual vs. Anglophone).

9) Family Medicine = Primary Care:

Unlike in the US, Family Physicians provide almost all primary care in Canada, along with nurse practitioners (in underserviced areas), Pediatricians (who are now being encouraged to pursue subspecialties and act as “consultants” instead of providing primary care), and General Internists (who rarely provide primary care, as they’re trained to be hospitalists and subspecialists). Family Medicine residents are the only ones who are trained in all aspects of primary care (patients of all ages, preventive care, and treatment of acute medical problems of all types). For those who feel strongly about preventive medicine, patient advocacy and continuity of care, Family Medicine is a great option.

10) Rural Family Medicine

Approximately 80% of Canadians live in urban areas, while the other 20% are distributed in rural communities throughout the vast country (the second largest in the world by area, after Russia).

Family Physicians who choose to practice in rural areas can look forward to exciting opportunities, as they may be the only permanent physicians there (specialists may only be available on certain days or in a neighboring community). Rural Family physicians may do all the deliveries, work in the ER, assist in surgeries, and act as hospitalists. The Family Physician may be the first physician to assess and treat a trauma victim, and the physician leading a resuscitation in the ICU. These activities are not thought of as being part of bread-and-butter urban Family Medicine, but they are certainly not unexpected for a Family Physician practicing in rural Canada.

Rural communities in Canada are generally considered “underserviced” and physicians are often provided with great incentives to permanently move there or to locum. Some of these communities are considered “fly-in” (not accessible by land or water), and doctors will often be flown into these communities to provide care on a temporary basis. This means that even Family Physicians who primarily practice urban family medicine can participate in the exciting aspects of rural practice.

Dahlia Balaban, MSc (@CdnMDStudent) is a Fourth year medical student and future Family Medicine resident at the University of Toronto in Canada with a special interest in medical education.