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Family medicine attracts record number of graduates


Family medicine was a popular choice among medical graduates in the 1980s, when Roger Strasser was training at The University of Western Ontario. “The residents had almost a missionary zeal that they were going to be family doctors,” he says.

He shared their passion, becoming a family physician. But when he returned to Canada in 2002, after going back to his home country of Australia, “the proportion of graduates choosing family medicine had plummeted,” he says. “It was in the doldrums.”

Strasser was back as the first dean of the Northern Ontario School of Medicine, which was created in response to the shortage of family doctors in Northern Ontario.

It was one of many initiatives to boost the attractiveness of family medicine. They seem to have worked – this year, 38% of medical students chose family medicine as their first pick in the residency match, the highest number in 20 years.

“To get to 38 percent was quite something,” says Kathy Lawrence, president of The College of Family Physicians of Canada. Family medicine was the first choice of more than 30 percent of graduates at all but three schools in Canada. Women and international medical graduates were more likely to pick it as their first choice, although the number of men who chose family medicine also rose.

That’s a relief after the drop in interest after the mid ’90s. In 1997, 35% of students chose family medicine as their first pick; by 2004, that number had dropped to 25%, before slowly coming up to its current high.

Canadians rely on family doctors: 90% say they’re the first person they’d turn to with a medical issue, and family doctors make up about 50% of Canada’s physicians. They have been linked to better chronic disease care and lower mortality rates overall.

Changing the model

By the mid-1990s, family medicine had an image problem: it was seen as lower paid and less prestigious than specialties were, and it was a job with demanding hours. At the same time, family doctor shortages led to concerns Canadians would face longer wait times, disjointed care from multiple providers and worse preventative care. But over the past two decades, family medicine has become more appealing.

One of the biggest shifts was an expansion of the types of primary care models after 2000. In Ontario, that included Comprehensive Care Models, Family Health Networks and Family Health Organizations. Alberta introduced Primary Care Networks in 2005, as well as Community Health Centres and Family Care Clinics.

By 2010, two-thirds of Ontario’s primary care physicians were in one of the new models; in Alberta, 75% of the province’s physicians are now part of Primary Care Networks.

The team-based setups offer better work-life balance and more collaboration. “They’re very cautious about the environment in which they decide to settle and to practice,” says David Snadden, executive associate dean of education at UBC’s Faculty of Medicine. “Lifestyles are important.”

In the 2012 National Physician Survey, 88% of family medicine residents who participated said the ability to maintain reasonable work hours was important to them, and 73% said the ability to work flexible hours was also important. The survey also found only 1% of family medicine residents were interested in working in a solo practice. “New graduates are interested in practicing medicine and caring for people, and not so much in running a small business,” says Strasser.

Showing them the money

Pay for family medicine has also gotten better. In Ontario, pay caps were removed in1998, and family doctors’ salaries have risen substantially since. Mean payments per family doctor grew gradually until 2004, when they were near $200,000, before seeing a more rapid rise to close to $300,000 in 2009/10, mostly thanks to payments through the new primary care options.

That’s helped make family medicine more competitive with specialties. “Ten years ago, there was quite a pay discrepancy between family physicians and specialists,” says Jonathan Kerr, president of the Ontario College of Family Physicians. “That gap has now narrowed.”

More residency spots may also add to the appeal. In Ontario, the number of family medicine spots has more than doubled over the past 10 years. And against the backdrop of reports that some specialists are having difficulty finding work, family medicine may seem like the safe choice.

Universities promote primary care

A decade ago, most students were exposed to many specialists and few family doctors. That led to a sentiment summed up in an article in the Canadian Medical Association Journal in 2001, when the number of students picking family medicine was declining. It reads: “[Dr. Paul Rainsberry, director of education with the College of Family Physicians of Canada] is worried universities are failing to promote family medicine as a career, in effect asking medical students: ‘Why be a family doctor when you’re so good?’”

Since then, many schools have developed Family Medicine Interest Groups, run by students and supported by the College of Family Physicians of Canada and the provinces, among other groups. They organize events at the universities and bring in family doctors to speak. “[We’re fighting] a hidden curriculum: that we’re being taught by specialists, so therefore specialists are most important,” says Lindsey Sutherland, a family medicine resident who was active in the University of Alberta’s rural medicine and family medicine interest groups.

Students at the Northern Ontario School of Medicine have even more exposure to family doctors. Fully 56% of its graduates picked family medicine as their first choice – the highest number in the country. Many of its classes are taught by family doctors, and rather than rotating through specialties, such as obstetrics in third year, their students work in family practice in a longitudinal integrated clerkship. They learn the same skills by treating diverse patients, such as pregnant women, in that setting. Having more family doctors as role models, rather than specialists and subspecialists, makes students more likely to go into the field, says Strasser.

The broader scope of practice, especially in rural areas, also provides a draw. Joanna Paterson, a research associate at the University of Northern British Columbia, interviewed seven family physicians in northern communities who graduated from the UBC northern medical program for her master’s thesis. “The strongest reason [they chose family medicine] was that they really wanted to have diversity in their practice, to serve all different kinds of patients,” she says.

Sutherland says the relatively short two-year family medicine residency also appealed to her graduating class. “There were a few people who were interested in [specialties], and then in their last year, they were like, I just can’t imagine doing another five-plus years” and they chose family medicine, she says.

They may also be attracted to the R3, or 2+1, option, where doctors take the two-year family medicine residency and then specialize with an extra year of training. It’s sometimes seen as a shortcut to careers such as emergency medicine. 

Location, location, location

Programs focused on northern, rural and remote communities might also be driving interest, says Snadden. The percentage choosing family medicine from Vancouver has been pretty much stable at around 30 percent, but in the North it was about 75 percent this year, he says. Students at those schools are more likely to practice in small communities, where family doctors are often the only health-care professionals.

The pull towards small-town living was a part of what drew Sutherland, who grew up on a farm in Chatham-Kent, to family medicine. She became enamored with the field after working as a researcher for a family doctor who became her mentor.

“I always wanted to go back home to where my husband and I are from,” says Sutherland. “I see they need family physicians, and that I can be most helpful to my community in that way.”

She’s not alone; the National Physician Survey found that one-third of family medicine residents grew up in a small town or rural or isolated community, and 36% of family medicine residents plan to work in that type of community.

That probably won’t solve the problem of shortages in underserved areas. “It’s been well shown that just producing more doctors doesn’t mean that those doctors will choose to practice in underserved areas,” says Strasser.

Health Force Ontario anticipates many rural or remote areas will continue to face doctor shortages. But thanks to the rise in interest in family medicine, along with record numbers of medical graduates, it did predict in a 2010 needs-based simulation model that Ontario may be close to solving the overall problem, saying that the province may have the right number of family doctors overall as early as 2017.

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18 comments

  1. Merrilee Fullerton

    16 % of specialists find themselves underemployed or unemployed despite graduating with skills that are greatly needed by patients in queues.

    %featured%Why spend additional years of training at great expense to train as a specialist when you can find work as a Family doc?%featured%

    And don’t forget the infrastructure needed to provide residencies for many specialties.

    The models of care are less significant .

    • Dr. Dennis Kendel

      Family medicine is a speciality with requisite competencies no less demanding than any of the speciality disciplines recognized by the royal College.

    • Robert Smith

      But what proportion of family medicine graduates specialize and focus solely on ER or obstetrics? I suspect it is increasing. That doesn’t necessarily help people looking for a GP who will follow them for the next thirty years.

      • Dr. Boon

        They never really talk about this because this would certainly make their celebratory hubris look stupid.

  2. sam sheps

    Fullerton is correct regarding the problem of specialist employment which stems in part from funding allocated to among other thing OR time. But the issue of primary care access is not simply a matter of to few doctors. Other primary care practitioners (e.g. nurse practitioners, physicians assistants, midwives) have yet to be fully engaged, particularly in rural and remote regions where doctors have always been scare and where they remain reluctant to go in any significant numbers. Moreover, doctors are not necessarily the answer given the huge increases in medical school enrollments and, as noted in the piece, above the significant increase in primary care income.%featured% Eventually provinces will get anxious about primary care costs a they did in the 1990′s. More doctors is only a part of the solution%featured% and will create problems for ministry of health budgets; organized medicine is however, a real part of the problem given their long standing reluctant to let other primary care practitioners into the mix.

    • Merrilee Fullerton

      It appears %featured%other providers generally decline to work in remote areas as well.%featured%

    • ben brooks

      let us not gamble on primary care quality.

      lesser trained midlevels have not been proven to reduce health care costs or be more efficient practitioners. their lack of training may even increase costs due to unnecessary testing, delayed or missed diagnoses etc

      patients also deserve to have doctors.

      midlevels are also more likely to go urban, just like mostly everyone. they will not increase access for patients.

      we need to go back to the general license. why there has not been more discussion regarding this obvious option is suspect.

  3. Dr. Boon

    This is not laudable.

    IMGs are a mixed bag, and the ones going into family medicine often do because they were not competitive or intelligent enough to get into a specialty.

    %featured%Family medicine has ruined primary care in Canada. The abolition of the general rotating internship combined with the lack of interest in family medicine from most medical students has decreased access to care for all.%featured%

    The new “increase” in family medicine applicants has nothing to do with attraction and everything to do with increased numbers of medical students without a proportionally increased number of specialist residency positions.

    I would also bet that a good number, if not majority, of those students in family medicine want to do a “plus 1″ like emergency medicine, sports, palliative etc and concentrate on that. True office-based family practice is not an attractive career.

    This is not something to be proud of.

    • Wernicke's Wit

      “The new “increase” in family medicine applicants has nothing to do with attraction and everything to do with increased numbers of medical students without a proportionally increased number of specialist residency positions.” <- this is exactly what the article is really about. I second the commenter above that with the increased CMG medical school spots and a restriction in specialist residency positions, people are being pushed into FM because there is no better alternative. Previously “less popular” specialities like psychiatry, PM+R, and internal medicine are also benefitting as well from this effect and becoming more competitive. See the recent CaRMS stats for more details.

      “Family medicine is a speciality with requisite competencies no less demanding than any of the speciality disciplines recognized by the royal college.”

      Oh if that’s the case, why isn’t FM a 5 year residency like everyone else?

    • Dr Sherlock

      And how, exactly, do IMGs differ from Canadian doctors? Do you have ANY evidence for your thoroughly disparaging comment about IMGs? – If so, I’d like to see it.

      Your comment is not laudable, Dr Boon. How do you think that reflects on you?

      • Dr. Boon

        The specialties that have the highest proportion of IMGs also tend to have the most problems.

        If you’re in Ontario, gloss over the CPSO disciplinary findings. You’ll see a disproportionate amount of infractions come from IMGs in fields like psychiatry and family medicine. I recall evidence in SK that over 90% of college complaints involve IMG physicians.

        Pathology is another field that is IMG heavy and we don’t have to look very hard to find multiple instances of errors and catastrophies.

        I’m concerned for patient safety, and the fact of the matter is that the quality of medical schools abroad is variable, with many being frankly bad, and we haven’t the faintest idea how to tell them apart. Nobody is going to say that an IMG from Oxford is incapable, but when we start going to second and third world nations , or proprietary for-profit offshore schools, from which the greatest proportion of our IMGs come from, we start to see variability in quality of practice.

        In short, often times IMG training is just not acceptable.

        I don’t think its appropriate to “roll the dice” on physician training quality in the name of multiculturalism and political-correctness.

  4. John Philpott

    CanAm Physician Recruiting strongly supports this article and the market trend in Canada. We repeatly advise medical students to do Family Medicine for the follow reasons;

    1. strongest need globally. Canadian specialist struggle to find options in desired locations

    2. a 2 yr Residency vs 4 or 5+ . The money you loose from not working is very difficult to recoup.

    3. %featured%Family Medicine provides the greatest forum to diversify. i.e ER/peds/geriatrics/clinic psyc/hospitalist/family medicine….etc%featured%

    4. flexibility to move and travel.

    5. own your business or work for someone else

  5. Zsofia Orosz

    The 2012 report of CIHI on “Supply, Distribution and Migration of Canadian Physicians” presented some pertinent data:
    • In 2012, there were more than 75,000 physicians in Canada, representing a 3.6% increase over 2011. Based solely on the number of MD degrees currently being awarded by Canadian universities, we can expect the number of physicians to continue to increase for the next several years. Between 2008 and 2012, physician growth rates outpaced population growth rates threefold, resulting in 214 physicians per 100,000 population in 2012.
    • In 2012, 37.4% of all physicians were women, compared with just below 30% in 2002, and in all provinces females were more likely be family physicians than specialists.
    • 18% of the Canadian population live in rural areas, 14% of family medicine physicians were located in rural parts. Between the 2006 and 2011 censuses, the population in rural areas increased by 1.7%. In comparison, between 2008 and 2012, the number of physicians in rural areas increased by 10.3%.

  6. Dr. Boon

    Why don’t any of these articles ask specialists why they didn’t consider family medicine?

  7. Bushra Rizwan

    Family medicine definitely allows for versatility in medical practice that most medical students find alluring. However, it would be interesting to know in a follow-up study out how many of the 38% of medical students who chose family medicine this year would be practicing in areas that are in dire need of primary care physicians.

    • Dr. Boon

      I would like to know what proportion of those 38% end up practicing true longitudinal Norman Rockwell family medicine (office visits, well-baby checks, inpatient, house calls), and what percentage practice only one thing that isn’t family medicine (emerg, palliative, derm, etc.).

  8. Cindy Backen

    With the aging population it is good to know that more medical students have leanings toward psychiatry, which is sorely needed.

  9. Name (required)

    The problem in Ontario is not a lack of family doctors but rather too many family doctors who setup walk-in clinics and don’t offer follow-up service. Plus most family doctors don’t offer evening or weekend appts, making it very difficult for people to actually get to a doctor without taking excessive time off work. To solve this problem, family doctors should be paid more for evening and weekends appts than for daytime appts. Many other businesses charge more for evening and weekend service, called off-hours premiums, who better than family physicains to do the same.

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