In the 2001 Canadian Resident Matching Service (CaRMS) final match, there were 38 unmatched positions in family medicine. In the 2022,CaRMS R1 (main residency) match, there were 225 unmatched positions in family medicine. While there is a second round of matching to come May 12, it is obvious that fewer and fewer medical graduates want to be family doctors. But why?
These are my opinions and naïve solutions:
First, let’s talk about money. Most medical school graduates have more than $100,000 in debt. Family doctors make an average $330,000 in gross income, spend about $120,000 in office overhead, pay $100,000 in taxes and therefore make about $110,000 in net income. If your monthly home expenses are $10,000/month, then you are already overspending. Remember, this does not include retirement savings (pension) or saving for a house; no holidays or paying off debt. So those numbers do not work. So, if you want to make more, then you need to go for the better paid careers: surgeons or cardiologists.
Naïve solution: All doctors need to be paid within one standard deviation of the average (not a three-times difference) or paid a salary with a pension.
Second, let’s talk about respect. How many specialists talk “down” the value of family doctors? Specialists often ask patients to follow up with their family doctors instead of explaining things or arranging follow-ups for various tests. I’ve often heard from specialists, “Family doctors have time to chat and fill out forms. Best to have your GP do that.” Plus, how many family doctors teach at Canadian medical schools (besides the community placements)? How many pharmacists and nurse practitioners are talking about doing most things that family doctors do? When was the last time family doctors were respected for their exceptional work/ knowledge/ expertise outside of being “primary care practitioners?” Sorry but unconscious bias against family doctors is alive and well.
Naïve solution: We need an equal number of family doctors and specialists teaching at all Canadian medical schools and we need to value each and every member of the MD family.
Finally, let’s admit family medicine is hard. Patients have high expectations (and typically bring their own agendas). It is not easy dealing with multiple comorbidities at one time. There are issues with secondary gain, mental health, compliance, misdirected anger for delays and uncertainty, multiple administrative obstacles (from IT issues to dealing with insurance companies to daily rule changes) and social determinants of health to manage. There is a need to act expeditiously. We don’t have an hour to work through a case (nor does it make financial sense). No wonder family doctors are burning out – and that few want to be family doctors.
Naïve solution: All medical school graduates should be family doctors first for five years after their two years of residency. Then, if they choose, they can train to be specialists.
I mean this article to be provocative. I want you to tear down my opinions and solutions. Let us find a way to make family medicine the first-choice career or calling for more medical school graduates. But at this rate of apathy and neglect, I don’t think it is likely.
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I am glad that some of the challenges with family medicine are being discussed. However, I believe that the issues run deeper.
With respect to the “respect” issue, many FPs in urban areas only practice limited scope partly due to financial reasons and partly due to practical reasons (e.g. difficulty maintaining a high-level of competency in multiple areas including ER, hospitalist, outpatient and obstetrics is probably almost impossible). As such nurse practitioners or other health care providers may be mandated to provide a similar level of outpatient care (e.g. as in BC) even though FPs clearly have much greater training and knowledge. So greater respect, and by implication higher renumeration may not be easily attainable. This structural issues run deep since FPs are generally incentivized to provide high volume care as opposed to spending more time with patients like NPs in BC. On the other hand, in many urban areas, focused areas like obstetrics are often covered by specialists meaning that training in the domain, during residency, does not result in any effectively greater scope of practice for graduating FPs. So, in urban areas especially, I think that FM has somewhat lost its footing – with patchwork solutions (like FHO/FHT) in Ontario having limited availability despite generally being a more attractive outpatient work environment.
On the other hand, in rural areas, even today, FPs do form the backbone of medical care and do practice a much greater scope in general. It seems as if this ideal of care is being used to inform the residency training process, but this ignores the increased push towards specialization and focus in urban areas – what may be acceptable as qualifications to work in say ER in a rural environment may not be acceptable in a urban environment.
Finally, there’s a great deal of regional disparity in scope and practice. Many of the unfilled positions are in QC, where much greater renumeration for almost all specialists as well as a hostile environment for FPs (limited PREMs/work permits in urban areas) may be driving people away from choosing FM – this is despite the fact that QC FPs do often practice in ER and obstetrics partly out of obligation.
Medical student here. Thanks for sharing your perspective and proposing solutions for this very real problem that we are facing in our Canadian healthcare system. I took an elective course comparing the healthcare systems and services of developed countries, and what I consistently took away as a core issue of why we have so many problems with primary care access is the pay structure of family physicians in Canada. In other countries, they use creative and innovative pay systems for their family doctors which incentivize (and reward) them to continue practising, take on additional patients (with attractive bonuses), or recruit more physicians to work in rural areas (preventing the situation where too many family doctors are concentrated in urban centres). FFS does not appear to be doing the job, and is simply encouraging family doctors to take on a higher volume of patients to keep their practice viable, at the expense of burnout.
Debt forgiveness would also go a long way towards improving the recruitment of family physicians. It remains to be seen though if there’s enough political willpower in each province to enact this level of change to the healthcare system.
Because I think we can all agree here: if primary care is improved, our population will be much healthier and the overall costs to the system will be greatly reduced.
Maybe medical school admissions should try to fill a quota for applicants who indicate an intention or make a commitment to practice family medicine? Maybe tuition should be less or waived for med students who commit to practicing family medicine? This would not only help produce more family doctors but it would dilute the culture of disrespect towards family medicine among medical students, residents and physicians.
Excellent. Ideas lead to change. Please share widely.
Hello Dr. Abdulla,
Thank you for your article. I too worry about the future of primary care. That said, my main concern is the concept of “forcing” graduates to practice family medicine for a number of years prior to specializing. As you mentioned in your writing, medical graduates are already experiencing debt, which will only be exacerbated if residency training is prolonged due to the nature of needing FM experience. I am also concerned that there has been many instances where people who dislike (or outright hate) FM provide suboptimal care, such as not bothering to listen to chief complaints, or not spending critical time necessary in mental health counselling and support. There are many examples of GPs who matched into FM as a backup during their CaRMS match and regretting their choice, having their negativity and pessimism spill into their clinical practice.
I do wish there would be better solutions one day. I only practice part time having completed my CCFP recently and am a PHPM resident, but I can see where people are coming from.
Good luck and take care sir,
Excellent. Unintended consequences abound in all ideas. We need to balance valuing primary care vs. allowing medical graduates to have autonomy of choice in their future. Does the present system allow that? If not then we needed a radical shift. Thank you.