Family doctor shortage: Medical education reform can help address critical gaps, starting with a specialized program

Recent reports indicate that more than 6 million Canadians are without a family doctor. This not only has a massive impact for those individuals, but also for the entire health-care system. Given current caseloads, about 4,000 family doctors would be required to address the current shortfall.

Education reform is part of the solution to this crisis. A new family medicine program in Ontario is designed to ensure that candidates who are the most qualified and motivated to pursue a community-based family practice get appropriate and comprehensive training.

The Queen's-Lakeridge Health MD Family Medicine Program focuses training and education on family medicine from the start of medical school, then advancing directly to residency. We were both involved in the conception and development of the program, Anthony Sanfilippo as senior advisor for educational expansion and innovation, and Jane Philpott as dean.

Current medical education

Under the existing system, medical schools across Canada welcomed about 3,100 young people in September. They are eager, academically accomplished and committed. They have succeeded (some would say survived) a grueling and competitive process that left the other 80 percent of their similarly accomplished and committed co-applicants disappointed.

Given the minuscule attrition rate after medical school admission and availability of postgraduate training positions, they are essentially assured of a career in medicine. That career, in today's expanded world of specialization and sub-specialization, could be in any of well over 100 distinct areas of medical practice. Some of those fields are in desperate need of new recruits, particularly family medicine.

Despite these pressing needs, students enter medical school with no commitment to any particular area of practice. Given current patterns of career selection, it may be as few as 700 medical graduates per year who will be taking up the comprehensive, continuing family practices that would address the needs of those patients.

In fact, much of their next three or (usually) four years in medical school will involve exploring various career options and engaging in yet another highly competitive and arduous process at the end of medical school to obtain a postgraduate training position.

In order to accomplish all this, their curricula will provide, in addition to scientific and professional skills common to all physicians, a broad sampling of specialties. This sampling will include learning, performance and clinical engagement in many areas of practice that they will never actually undertake or, if they do, will need to relearn and refine in their postgraduate training program.

What's clear is that, without significant reform, modest expansion and even opening new schools will not come close to addressing our needs within the current training paradigm.

A program specific to family medicine

This year, for the first time, things will be different for the 20 students entering the new Queen's-Lakeridge Health MD Family Medicine Program. Their admission was based not only on exemplary academic and personal credentials, but also on their commitment to a career in family medicine.

The program they are about to undertake is designed deliberately to prepare them for those careers, will include early clinical learning in family practice settings and will be taught predominantly by family physicians who are in active clinical practice providing the comprehensive, continuing, community-based care so desperately needed in our country.

It began as a partnership between Queen's University School of Medicine and Lakeridge Health, an integrated organization of five hospitals and over 20 community health locations providing care to the residents of Durham region. It was based on a shared recognition that medical schools have a role in addressing the critical shortage of family physicians impacting so many Canadians, and that this shortage can, in part, be addressed by providing specialized admission opportunities and more purpose-driven education to motivated applicants.

It also seeks to develop models of medical education that address the real needs of contemporary society, evolving in response to the expansion and diversification of medical practice. Medical problems that were previously treated exclusively in hospital or required only palliative management are now very effectively managed chronically with medication and regular follow-up in the community.

Durham Region provides an ideal location for this program given its increasing and highly diversified population. It's also home to multiple, well developed medical practice settings (including acute care hospitals, chronic care and mental health facilities, ambulatory clinics, and both group and individual practices) as well as committed medical and administrative communities who have longstanding associations with Queen's.

Queen's School of Medicine and Lakeridge Health jointly proposed, and were supported by the Ontario Ministry of Health, in the development of this continuous six-year program that would prepare students to become qualified family physicians focused on providing comprehensive, continuing, community-based care.

Themes specific to family medicine

A joint Queen's-Lakeridge Health Working Group was established to explore and implement the program based on four key themes:

Admissions—After identifying attributes appropriate to a successful career in family practice, a novel admission process was developed that assesses academic aptitude for medicine as well as personal qualities and commitment that will promote both practice satisfaction and retention within communities.

Curriculum—A novel curriculum was developed focused on fundamental and clinical training relevant to family medicine, with early and continuing placements in community practice settings. The curriculum incorporates key components of the undergraduate MD program and postgraduate family medicine program into an integrated program without the necessity for a secondary application process. The concept is that students will learn how to provide care to patients of all ages, in the types of settings in which they will eventually practice.

Faculty Engagement—The faculty team blends Queen's instructors based in Kingston with newly recruited faculty members in the Durham Region medical community. New faculty are welcomed into the Queen's teaching community with an orientation and instruction process. Students will be learning from doctors who are actively involved in the type of practice in which they are training.

Community Engagement—The new program is located in Durham Region. Together with Lakeridge Health administration and medical staff, facilities for teaching, housing and community placements have been established. In addition, student support and counseling have been developed locally, with strong support and integration with Kingston-based services.

Addressing a critical gap

These students will be able to undertake studies and training that will prepare them for their intended career, in the sort of settings in which they will eventually practice, and with guidance and mentorship of practicing faculty. Their learning will be focused on family medicine. They will not be required to undertake any secondary application process, and will have considerable flexibility to tailor their training to the requirements of their eventual practice destination.

The aim is for them to emerge from the program prepared to qualify and practice as family physicians.

Importantly, this approach, although designed at this point for family medicine, could serve as a model for other medical specialties to address current and future medical workforce requirements.

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