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.