To the editor:
Extra! Extra! Read all about it. Family medicine training is to be extended by a year!
Last year I wrote part 1 on this subject: The shortage of family doctors, the many roles family doctors play in North Bay, and the need for creative solutions to the shortages. Looking back I’m still happy with what I wrote. So, why am I motivated enough to write part 2?
See: The northern Family Physician: A rare & fantastic breed
Fear? Desperation? Am I allowed to say that in an article?
There is a very real possibility that the training time for family medicine doctors will be extended by a year. This will start in 2027. Why is that a concern? Let me lay out my thoughts.
What are the pros of extra family medicine training?
Family medicine encompasses a broad range of knowledge. I divide it into three basic areas:
1. Learning to identify and hopefully prevent health problems that could lead to loss of life.
2. Learning how to prevent health problems that will lead to lifelong disability. And,
3. Taking care of people’s basic needs and psychological well-being.
Now there are many types of doctors and some of this work is assisted by referring to heart doctors, cancer doctors, internists, pediatricians, surgeons, and so forth. Typically, we take care of a health problem to the highest level we can and then ask for help from a doctor who specializes in that area.
What happens when there aren’t enough specialists?
Anyone who has accessed medical care in the last year will realize that there aren’t enough specialty doctors for the work either. Life-threatening conditions are being prioritized but what does the rest look like? Here are some examples from our community:
- Neurology referrals: 9-12 months
- Ear, Nose and Throat (ENT) specialist referrals: 9-15 months
- Gynecological referrals: 9-15 months
So, what does this mean for the family doctor?
Neurology:
I have had 3 patients in the last year who have had to wait 9-15 months to see the specialist. That has meant disability that goes untreated and sometimes the inability to work. I have had to pull out neurology books and try to find tests that might allow me to make a diagnosis sooner just in case that allows me to come up with a solution that will let them get back to their jobs and lives. (But it's a complicated area. There is a reason this area takes 7 years of specialty training)
ENT:
The Ear, nose, and throat doctors in our town are appropriately prioritizing cancer and surgical problems. So, now I’m sending non-surgical problems that need extra expertise to Barrie.
Instead of just sending suspected skin cancers, I’ve had to start doing biopsies to help these referrals to be prioritized appropriately.
Gynecology:
Getting an IUD put in for pregnancy prevention generally takes 12-15 months. This is a long time for a teen to wait to get reliable contraception. (Oral contraception is great but it's easy to forget to take a daily pill.) Some of my family medicine colleagues have taken the extra training needed to put in an IUD so this is shortening the wait for some. However, having another family medicine doctor see your patient means that the government retracts the payment for that service from what they would ordinarily have paid their regular family doctor to take “full” care of that patient.
Cancer doctors:
In order to make sure new patients can be seen swiftly, (Super important) they are discharging lower-needs cancer patients to family doctors after two years of care instead of the normal five. Once again, new learning and new tasks for us.
If you think about it, 4 years of medical training and 2 years of family medicine specialty training don’t seem like enough to know how to do all of this. Many residents who are graduating are not feeling ready.
So, clearly, the answer is that it makes sense that extra training is 100% the way to go, right?
And just as clearly, I’m about to tell you the exact opposite.
What are the Cons of a third year of training?
Point number 1:
Medical knowledge is an ocean of information. In our six years of training, we empty 6 buckets out of the ocean. They are proposing one more year of training to get one more bucket (number 7) out of the ocean.
I have spent the last 25 years continuing to learn and taking extra buckets out of the ocean. I still find things I don’t know every single week I work. (Unfortunately, as I get older my bucket has become a little leaky. But we won't talk about that.)
Will one more year make a critical difference in their knowledge base and ability to function as a family doctor? I would say no. This is lifelong learning. The best knowledge to come out of training with, is knowing your limits, knowing the holes in your game, and figuring out when you need to learn more or ask for help.
Point number 2:
If we make the training longer, many more doctors will choose to train as specialists further depleting the pool of people going into family medicine. The shorter training time in family medicine has always been one of the points in favour of choosing family medicine. Adding a third year of training really shrinks that gap. On top of that, the specialties are higher-paying fields and “sexier” sounding areas.
We are ALREADY not filling the available training slots for family medicine doctors. Hundreds of family medicine training positions went unfilled across Canada this year.
Point number 3: What are the downsides to the third year for communities?
If you remember from the last article, I said North Bay was barely keeping up with the family doctors who were retiring. In this last year, I’ve become uncertain that we are even doing this. All of Ontario is short of doctors, not just North Bay, so it is super hard to recruit.
While we are short of family physicians in the community, it's a little-known fact that our Emergency room is also largely staffed by family doctors. It needs to be kept open 24 hours a day.
See: Wait times for emerge going to get worse say doctors
That means we would need a minimum of three doctors just to be able to have one person in the department at a time over a 24-hour period. This is not enough for the volumes that come through our emergency department. We ideally staff with 8 doctors a day. That gives us double and triple coverage.
This is especially important if several emergency cases come in at a time. Meeting this staffing goal has been a struggle over the last 2 years. However, for the last 4 months, we have only been able to staff the department with between 4-6 doctors a day. The time-critical and serious health problems are seen first. Unfortunately, that means that those health concerns that can wait, have waited up to 17 hours to be seen.
We have been energetically trying to recruit but there simply aren’t enough physicians right now in Ontario. You only have to scan the news to hear of how many Emergency departments have had closures due to staffing problems to know that recruiting has been an uphill battle for everyone.
I have gone back to doing emergency room work for the first time in 8 years to help out. Other family doctors are doing their best to step up too. This has allowed us to get up to 6 shifts on some of the days. But remember, this is drawing from the same pool of family doctors trying to keep everything else afloat. Which analogy shall I use? Rearranging deck chairs on the Titanic? Yup, I'm going with that one.
So what happens when we have a gap year when NO family doctors are graduating? I will leave it to your imagination.
The addition of the third year of training for family medicine doctors is slated to start in 2027. Most of us feel it's a juggernaut that we have no way of stopping. I am hoping that that is not true. I feel that we have to find some way of stepping up as a community and participating in this change.
This is a call for help!
The doctors are simply too overwhelmed and too short of time to lead this charge. I’m hoping this fires the imagination of the community and that someone can step up and dig into this issue.
This is an opinion piece based on my experience in the community. If there is anything I’ve gotten wrong, or misrepresented, or if there are other points of view, I’d love to hear back in the response threads. Please, please, adjust my current perspective on this.
Dr. Sheryl Riley
Callander
Family doctor, walk-in doctor, hospitalist, preceptor in training new doctors, and no longer an ex-emergency room doctor.
