Sunday, May 21, 2017

Does Family Medicine Have a Future? Part IV

Don't prescribe the solution until you understand the problem.

As I noted in my last post, Family Medicine is in deep trouble in Canada. Though more medical students are choosing careers in Family Medicine than was the case a decade ago, the trend is heading back downwards. Worse still, training in Family Medicine does not necessarily mean a student will end up as a full-service Family Doctor. Some 30% (if not more) graduating residents either restrict their practices or focus on "subspecialties" of Family Medicine: Emergency Medicine, Palliative Care, Chronic Pain, and so on.

Most worrisome, however, is that the most basic approach to policy problems - economics - doesn't appear to have worked. Governments across Canada made massive investments in reforming Primary Care from the mid-2000s onward, the rate of unemployment in competitive specialties is ballooning, yet Family Medicine remains an undesired career for the majority of Canada's med students. If it's not money or job prospects driving the disinterest, what is it?

It's impossible to believe that there's a single causal factor here. The situation has persisted for decades, thorough years of funding cuts and years of largess, years of incentives and years of restrictions, years of discount tuition and years of exorbitant tuition, and seismic shifts in the demographics and work patterns of the physician workforce. Since doctors, policymakers, and the public are in agreement that there's cause for concern, it's no time for best guesses and remedial half-measures.

As I see it, there are two fundamental questions that need to be answered:

1. Why don't medical students choose Family Medicine?
2. Why don't trainees choosing Family Medicine ultimately practice Family Medicine?

The first question is ultimately one for the medical schools. Is there something about the way Family Medicine is taught that leads to disinterest? It there enough exposure, or over-exposure? Is the career counseling in med school (or in undergraduate schools) both adequate and accurate? Does that counseling cover both the real job demands and realistic job prospects? Is there something about how and which students are accepted to med school that contributes to the problem?

The second question will be the more difficult to answer, and the answers might very well differ from one jurisdiction to another. Is it the economics of practice in some jurisdictions, but not necessarily in others? Is it the administrative demands, that again might differ from place to place? Is it family or cost of living considerations? Is it the complexity of care that's a turnoff? Is the work too challenging or not challenging enough? Lack of support services?

Getting to the bottom of this will require serious time and energy, with the urgency and intensity of a judicial inquiry. Electronic surveys will simply not cut it, even with a good sample size. Medical students, Family Medicine residents, and practicing doctors need to be interviewed in-depth and in a semi-structured manner - the same questions need to be asked of everyone, but leeway is needed to explore issues as they're uncovered. These interviews need to be done by a body like the College of Family Physicians (CFPC) or Canadian Medical Association, that has no direct authority over someone's career. A resident is far more likely to tell her program director what she perceives the program director wants to hear, than to deliver the unvarnished truth.

Once the work is done, then comes the hard part. The CFPC and medical schools need to face and accept the themes coming out of this endeavor, and act upon them. If med students are ill informed about the realities of practice, they need more comprehensive career counseling to set the record straight.  If med students don't believe Family Medicine is challenging enough, they need new and diverse experiences (get them out of the city!) If residents don't feel comfortable dealing with complex patients, the curriculum will need a tweak.

There is one uncomfortable truth, however, that the CFPC (and to some extent, the Canadian public) must prepare itself for: it's quite possible that the ideal of how Family Medicine "should" be practiced does not appeal to, and is irreconcilable with, the majority of current and future doctors' personalities, desires, and expectations. Again, we are in a situation where economics has not fixed things. Money's been poured into primary care, but medical students are still opting for specialties, even those with lousy job prospects. There is a policy shift that can address this part of the problem, and help with chronic staffing problems in small communities, but that's a topic for another post.

Here's where I probably burn my bridges. I speak only for myself, but it's time to acknowledge that the "ideal" of comprehensive Family Medicine and the (romantic) Patient's Medical Home belies the complexity and intensity of modern medicine. There aren't enough hours in the day for doctors to be caring medical experts on the one hand, and team-based, prevention-focused, data-driven, guideline-obedient drones on the other. That policymakers see no problem in Nurse Practitioners assuming much of the workload would seem to reinforce that notion.

The idea of the "perfect" Family Doctor is just that - an idea. It's words on the page composed by a committee, not a living, sentient medical professional. It's long past time to examine the intense realities of the job, listen to the people toiling away in the job, acknowledge the rationale of those rejecting the job, and act.


  1. I think you dismiss the economics of it too quickly. All the money Ontario poured into FHTs and FHOs about a decade ago I believe was correlated with an uptick in Family Medicine as first choice. When I graduated it was a very exciting time to be a Family Physician. However, I know myself and several colleagues that are becoming more and more disillusioned with Family Medicine (an attitude which rubs off on residents and clerks we teach, I'm sure) with the ongoing cuts to these models. No more support for CME. No more bonuses for signing on new patients? Fine, I haven't taken on a single new patient in 3 years. No more DM management bonus? I'm much more likely to refer my patient to Endo like they demand instead of insisting I manage it myself. I do OB and Women's Health work, and when overhead and paperwork is factored in, my comprehensive family practice is by far the least well paid. So when I need a day to chill with my family or whatever, or find I am swamped and want to cut my hours - I cut my office hours, and not my surgical clinics or OB call. And (for what a small and biased sample size is worth) many of my colleagues feel similarly. I don't think it's the only reason, but I wouldn't dismiss it out of hand.

    1. Thanks for the comment! I didn't mean to dismiss money out of hand, but rather to point out that major primary care investments and increases in MD pay still left the proportion of students choosing Family Medicine topping out at a third. (Yes, the number was closer to 38%, but one tenth of grads are bound for an EM year to work emerg full time.)

      On top of that, you have the large numbers of new docs not interested in OB, house calls, etc., or restricting their practices out of the gate. And now we have the absurd situation of students chasing disciplines with very high rates of unemployment rather than Family Medicine.

      What you've described is of course increasingly common these days, but more about family docs' satisfaction than their chosen career. You're a comprehensive family doctor, full stop. Does that dissatisfaction rub off on clerks? Probably. But how many students have made up their mind well before their clerkship rotations.

      It's possible that I'm 100% in the wrong, but nobody will know until the CFPC starts asking trainees WHY they're choosing how they are.