We cannot teach ourselves out of a failing system

As a health services researcher with an academic and clinical interest in complexity, I find the College of Family Physicians of Canada’s (CFPC) notion of “educating ourselves out” of the current health-care crisis confusing.

The college recently announced plans to extend post-graduate medical education by a year, with the first three-year program expected to begin in 2027. It posits that a longer training runway is needed to develop the skills required in an increasingly complex health-care environment. Educational reform is one strategy the college says it can contribute to addressing the current health human-resource crisis by “preparing family physicians for emerging and complex societal health-care needs.”

The evidence is overwhelming that the Family Medicine community is facing an existential crisis – recruitment is dwindling and retention is challenging. There is also widespread concern that health care in Canada (and the health of Canadians) is at great risk if primary care collapses.

But the big question here is: What is the evidence that we can train our way out of this current state? And what might we lose if we direct our limited energy and resources to a well-intended (but I argue, weakly supported) reform to family physician training?

The recommendation to extend training emerged from the CFPC’s Outcomes of Training Project (OTP) Report. The goal was to outline the “educational prescription for strengthening Family Medicine in changing times.” The OTP consisted of consultations with Family Medicine leaders, frontline physicians and trainees to identify barriers to and facilitators of comprehensive family medicine practice. Systematic and rapid reviews were also completed to address the central question: What must we do to prepare and better support our future family physicians?  The findings of the OTP consultations and reviews can be summarized under the following themes:

1. Our ability to measure the impact that our current Family Medicine graduates have on the health system is limited due to poor data quality and infrastructure.
2. Family Medicine is much more than primary care but the number of graduates practicing in comprehensive medical practice is declining.
3. There are several systemic and environmental factors that influence early career practice choices.
4. Canada has a comparatively short duration of training.

While many of the reports in the OTP were developed internally and not peer-reviewed studies, these themes will resonate with many, and to that extent have compelling face validity. But will curriculum reform and more months of post-graduate training substantively address any of them?

Well, the absence of high-quality, granular data on how training competencies map to patient experiences and outcomes makes the evaluation of any change in residency training nearly impossible. Currently, we have no ability to know how graduates from any program in Canada are contributing to the health of Canadians. This is a stunning reality on its own, but particularly distressing when a major change in training is being proposed with no baseline patient-centered or learner-centered data to even know if we are making progress where it matters most.

We do have the ability to examine physician billing data, which at least provides some ability to evaluate the types of care being provided via service and diagnostic codes. A 2023 study examined trends in comprehensive care provided by family physicians in Ontario, British Columbia, Manitoba, and Nova Scotia at specific periods in time (1999-2000 and 2017-2018). It examined services delivered and determined patterns of comprehensiveness using a data definition that accounted for type and location of service delivery.

The study found a reduction in comprehensiveness over this time, but the narrowing of scope of practice was most noted in male physicians who had been in practice for more than 20 years.  This suggests that loss in comprehensive care is not due to the absence of skills as physicians transition to practice, it is an absence of systemic supports to maintain comprehensiveness. Education will not address systemic and structural barriers.

Education will not address systemic and structural barriers.

The environmental and systemic factors that undermine comprehensive practice are numerous. Increasing administrative burdens and use of digital technologies are pulling physicians away from direct patient care. The antiquated fee-for-service payment model incentivizes patient volumes over time spent with patients and contributes significantly to the gender pay gap among practicing physicians. To be clear, Family Medicine is not a lucrative discipline, but payment models matter when family physicians are also small business owners who need to cover clinic overhead, equipment and personnel costs. To ensure the economic survival of their practice, physicians do need to make the payment model work for them. But let us be clear, the choice of volume over time does come with moral distress.

Moral distress and burnout are significant drivers of physician attrition in all disciplines. The 2021 National Physician Health Survey demonstrated that 53 per cent of practicing physicians reported a high degree of burnout (among family physicians, 57 per cent reported burnout). Collectively, the data would suggest that systemic factors are hurting all physicians, and while the determinants of family physician’s ability to practice comprehensively may be discipline specific, individual focused training will never address systemic or political issues that keep their patients ill and interfere with their sense of professional effectiveness. Medical residency is a difficult time for young physicians, particularly equity deserving learners. Extending training increases exposure to certain harms (intimidation, bullying and harassment, for example), so any extension in training must be accompanied with a robust plan to ensure psychologically safe training experiences.

Somewhat ironically, the CFCP has cited the need for more training in Equity, Diversity, Inclusion and Accessibility (EDIA) and anti-racism as a reason to extend training. Indeed, as a profession, we have a lot of work to do to ensure safe and respectful care, but this is a shared responsibility and one that needs a pan-professional commitment to culture change and humility. An additional year of training in one discipline cannot be reasonably expected to make the needed change. Culture change starts with leadership and accountability. Placing this responsibility on trainees, particularly equity-deserving trainees, is deeply unfair.

The OTP refers to our current two-year program as being one of the shortest among Organization for Economic Cooperation and Development countries as a reason to extend our training.  This is ridiculous. There is international variation in how and when students are selected for medical training and very different health-system contexts. Saying that Ireland has a four-year training pathway is true, but it also neglects to mention that in Ireland, students can enter medical school upon graduating from high school; there is no requirement for an undergraduate degree. Context matters.

The reality is that the CFPC can institute this change on its own. It has the power to implement, regardless of how physicians feel. We need our professional colleges to credential us and accredit our institutions and programs. The accountability framework is one in which we are accountable to the colleges, and the colleges are accountable to the citizens. We need to examine if this model really works. The Royal College of Physicians and Surgeons has been criticized for being oblivious to how its definition of competencies contributes to systemic racism (while working diligently to address this, the impacts of these efforts are not yet known). Program accreditation is not helpful at ensuring quality but excellent at making programs divert time and attention to ensure trainees know how to clear an accreditation bar. The accreditation process encourages accreditation behaviours, none of which track to patient care or experiences (well, they might but remember we have no data to say this with any degree of confidence).

The amount of power the colleges have and how this power is used is central to this discussion about training expansion. If the CFPC is truly accountable to citizens, it is hard to justify this policy. Citizens have not been engaged in the decision and the data to justify the decision is limited (if not more supportive of the current state).

The CFPC has committed to working on system changes and improving access to care for Canadians (in part by expediting credentialing of international medical graduates). This is excellent and very well supported. This expansion of training is ill-conceived and will demoralize and financially penalize early career physicians. Decisions always have consequences, and I fear this one will generate waves of demoralized physicians across the continuum of care.