Another year? Yes. Make it a good one, and share it with specialists, too.

Adding another year to the family practice residency may be controversial, but it is a good idea.

When I first heard about this five years ago, Gigi Osler was the president of the Canadian Medical Association. I emailed her to suggest that this would be an opportune time to extend specialty training by a year as well. Many specialty training programs would benefit from this change. Residents would have more time to work within their curriculum, with their mentors and to gain valuable clinical experience. Most doctors finishing residency go on to complete one or more years additional of fellowship training in sub-specialty areas of practice. They will either move into these niche markets of specialization or maintain a general practice of their discipline with a special interest. Regardless, the extra time spent studying, working with experts and accumulating experience will serve them well whatever their eventual career path.

A resident or a fellow is less expensive to the health-care system than a practicing physician. A better trained physician is less expensive to the health-care system. Having more residents in the system will decrease the workload of trainees, improve their work-life balance and support their busy clinical and academic mentors. There will be fewer nights on-call, more time to study, more time to focus on the nuances of clinical practice, more time to get to know and be known by the faculty and more opportunities to be given responsibility. These are all the goals of a good training program.

So, I say, let’s add a year of post MD training for everyone, not just family practice.

Where is this year likely to be most valuable?

In my opinion, this additional year should be at the beginning of residency. Ever since its demise in 1994, the “rotating internship” has been mourned. It’s time for a resurrection. The basic science years of medical school are the time to learn facts: anatomy, physiology, pathology, pharmacology. The early clinical years are a time to learn skills: history taking, physical examination, knot tying.

The clerkship, during which medical students work as the most junior members of the team on all the core service disciplines in medicine, is a time to begin to integrate knowledge and skill into the practical approach to caring for patients and an opportunity to bring the attitude of caring that brought them into medicine in the first place, into the clinics and onto the wards. But this year is also the year of CaRMS, the Canadian Resident Matching Service. Medical students must decide on their long-term career path before getting to see the full scope of what medicine has to offer them. Most will be happy, but some will wish they had made a different choice. They can’t go back and it’s hard to change. The year for many is a prolonged, expensive adventure of travel, electives and auditions culminating in the “match.”

Ever since its demise in 1994, the “rotating internship” has been mourned. It’s time for a resurrection.

The first year after graduation should be devoted to becoming a whole physician. After medical school, there are numerous gaps in knowledge, skill and experience. How could there not be? No one has completed their 10,000 hours! A year of “rotating internship” as the PGY-1 year for all graduates would provide the broad education and experience needed for these physicians as they gradually become skilled doctors, then skilled family physicians or specialists and then even sub-specialists in niche markets of family practice or specialization.

All physicians need to know something about the real-life practice experience of their colleagues. None of us works in a vacuum. We all share the care of patients, some of whom have a complex constellation of medical problems. We all need to understand the ways in which other people look at and practice medicine, how it affects our practice and our patients’ care. We need to know how and what to communicate with each other. A year of rotating internship would give newly graduated physicians the experience they need to move forward in their careers while also grounding them in the disciplines of all of medicine and helping them to see their place within the entire community.

I have been in practice for more than 30 years. I did a rotating internship. Things that I learned about how my colleagues in other disciplines look at and practice medicine have served me well over the years. I have an expanded knowledge and skill set. My understanding of my colleagues’ medical lives has made me a better communicator and a better collaborator. I am prepared to advocate for my colleagues in other disciplines and help manage and lead at the committee table. I have done research with colleagues in a variety of disciplines, and this has broadened my perspective further as learning from my colleagues has allowed me to bring back to my office and my hospital and my operating room experiences that directly benefit my patients. I can bring this perspective to my teaching.

This understanding of medicine as a macro-profession, as opposed to pediatric craniofacial surgery as a micro-profession, has also meant that I have developed excellent relationships with my professional colleagues and has allowed me to serve in professional roles with my medical staff association, my medical advisory committee, my provincial college, my provincial medical association and various national and international societies. It has allowed me to appreciate things that I have learned working on surgical missions from colleagues practicing what I practice but in very different circumstances.

All of this I attribute to having a well-rounded education that I attribute to completing a rotating internship and carrying the lessons learned from a diverse family of experienced teachers.

All the students, all the residents, all the fellows, all the teachers, all the clinicians, all the academics, all of the system and, most importantly, all patients would benefit from a more complete education of all doctors in their PGY-1 year. This education is foundational and is something that will be invaluable to them throughout their careers.

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2 Comments
  • Dr. S. Kim says:

    You want staff physician skill at resident prices. Specialists and family doctors.

    If I were a government bureaucrat I’d be salivating over the huge savings! Imagine what they could do with it! They could solve climate change! /s

    Training should be reduced in time, not extended. It’s so long because of mostly inefficient grunt work made necessary by inadequate ancillary staffing, a convenient problem orchestrated by hospital associations. Why hire nurses, porters and techs when you can get one resident to do all of that work for the price of not even half of a nurse!

    You drank the administrator Kool-Aid when you should have spat it back.

  • Paul Conte says:

    The arguments put forth for extending training for family practice residents by a year are weak because (1) it focuses on all residents not just family practice residents (2) the blanket argument of more is always better is not supported by evidence and (3) it focuses on medicine in isolation from other professions in health care and ignores the current environment including the worsening economics of community based family medicine. What happened over 30 years ago is simply not relevant today. I find the perspectives and arguments put forth to extend family practice residency by a year coming from an academic plastic surgeon pretty rich…

Authors

Douglas Courtemanche

Contributor

Douglas Courtemanche is a plastic surgeon with an interest in cleft and craniofacial surgery. He is a Clinical Professor of Surgery at UBC and works at Vancouver General Hospital and BC Children’s Hospital, where he is the Director of the Vascular Anomalies Clinic at BC Children’s Hospital. He is a member of Doctors for Planetary Health – West Coast, working for social and environmental justice and challenging colonial structures.

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