Preparing our Future Family Physicians

1. Canada’s family physicians are competent, well trained within university-based residency programs, and meet the high educational standards established by the CFPC.
2. The CFPC has undertaken a critical review of family medicine training and made recommendations through Preparing our Future Family Physicians: An educational prescription for strengthening health care in changing times, so Canada’s family doctors can continue to meet the evolving health needs of patients and communities.
3. It is essential to better link education with practice and to support graduates to practice in a way that we know to be most effective and professionally fulfilling. Training enhancements that expose learners to the Patient’s Medical Home practice vision that will allow them to learn from other health professionals and build competence as part of an interprofessional team.
4. Recommended changes to training, including adding a third year, are geared toward improving patient access by enhancing the ability of family physicians to:
   • Care for patients and communities with changing and complex health care needs in a range of settings
   • Incorporate new technologies to improve access and continuity of care
   • Practice in rural and remote areas
   • Provide care that is culturally safe
5. The CFPC will work closely with universities and other key partners to support the change process. Changes based on the recommendations will be reflected in the CFPC’s educational standards starting in 2027 with more details forthcoming.
6. Recommended educational changes are necessary but insufficient on their own to improve access for patients. Education and health system reform as per the Patient’s Medical Home must be combined to realize the full potential of family medicine in a transformed health care system.

Why Did the CFPC Conduct the Outcomes of Training Project (OTP)?

These are dynamic and changing times. We want to ensure that training keeps pace with the evolving role of family physicians, medical and technological advances, as well as societal health care needs and trends. We want to ensure that all graduates are ready to practice full scope family practice anywhere in Canada, particularly underserved communities, and that they are supported in their transition to practice. The OTP established an educational continuous quality improvement (CQI) process where we defined our desired outcomes, evaluated training relative to these goals, and made recommendations for improvement. These recommendations were published in January 2022 as part of the full OTP report along with 11 evidence summaries that informed this critical analysis (www.cfpc.ca/futurefp).

1. Family medicine training in Canada is excellent and we want to keep it that way – this is about CQI in our educational standards.
   Maintaining high standards requires periodic review and adjustment of curriculum. This is a natural evolution, and not a criticism of current training. As an organization we are very proud of, and grateful for, Canada’s family physicians.
2. We did our homework and consulted broadly, according to the question at hand.
   To understand the realities of family practice and how that is changing and how residency should evolve, we conducted field research with hundreds of family physicians and experienced educators. This resulted in the Residency Training Profile (www.cfpc.ca/rtp), which was released in May 2021. To understand the resources required to deliver on training enhancements we consulted with university program leaders (program directors and department chairs). To gauge impact and learner perspectives we consulted with the CFPC Section of Medical Students and the First Five Years in Family Practice Committee. For evidence on preparedness and optimal length of training we conducted a mixed methods analysis including literature review, an international environmental scan, focus group interviews with early career family physicians, and analyzed data from the CFPC’s Family Medicine Longitudinal Survey. Summaries of this evidence are on our project web page (www.cfpc.ca/futurefp).
3. The educational recommendations support a vision for the future of family practice.
   This vision includes family physicians providing more complexity care, working in teams, and improving access and care for and with underserved communities. Other care providers, such as nurse practitioners, will increasingly be involved with routine care, while family physicians take medical leadership for more complex patient care and continuity of care across other settings including hospitals. This is based on consultation with practising family physicians and reflects current realities, challenges, and aspirations for the future of the discipline.
4. Enhancements are needed to strengthen preparedness and address societal needs.
   Such enhancements include more opportunity for skills consolidation particularly in domains such as acute care, procedural skills, and complex care; for the deepening of skills in priority areas; and to gain more, varied, and advanced practice experiences as part of a better supported transition into practice.
5. Longer training allows for necessary enhancements not possible within the current two-year period.
   We shouldn’t be surprised or critical that we struggle to fit it all into two years—we are seriously under resourced (where time is an important training resource) by international comparisons. Canada has the broadest scope and shortest family medicine training in the world when compared to other countries, such as the United States and Australia (three to four years) where family physicians are also involved in providing hospital, emergency, and obstetrical care, and serving rural and remote communities. Consultation with educational leaders confirmed that training needs to be extended to accommodate the recommended changes.
6. Medical students value education that leads to a fulfilling career.
   There are questions and concerns about how students will react to the prospect of longer training, and we have had some discussions with student leadership about this. We know now that student interest is high in “plus one” enhanced skill training, and so it is clear that students are willing to put in the extra time if it leads to a desirable outcome. This is where active efforts to bring about changes in practice become critical, and where opportunities for educational innovation linked to practice can help. Preliminary results from pilot studies in the United States looking at extended four-year training in family medicine show promise. Participating schools did not show any decline in applications, and those students most interested are those particularly bent on full scope practices that include other dimensions such as hospital care. In our consultations, concerns centre around income and debt loads—the CFPC shares these concerns and is actively advocating on the issue of student debt relief.
7. Longer training is a recommendation – planning for implementation has just started.
   Longer training is not a mandate nor immediately feasible for programs at present. There is a long way to go before this is a reality but we are working toward it. We are at the very beginning of the implementation planning phase looking at resources, risk mitigation, and partner relations. For this work to occur, there will be no changes to CFPC educational standards for at least five years.
8. The CFPC continues to support enhanced skills training and Certificates of Added Competence (CACs).
   We fully support CACs as critical to care in rural and urban communities with a reinforced focus on advanced care and leadership. Residents should not need enhanced skills training simply to include things like obstetrics, palliative care, long term care, etc., into full scope practice. The reconfiguration of this relative to core training changes will be modelled over the next 1.5 years; therefore, there is some uncertainty at present. We will work with educational partners and specialty societies in planning for change.
9. This is a tough time for a big change and we will adjust as needed.
   We want to thank family physicians/educational leaders for their extraordinary commitment and service during the pandemic. Recovery may take a while. Capacity for change may be limited. Concerns exist about declining interest in family medicine as a career choice by medical students. All of this contributes to what we see as a crisis in family medicine, which the CFPC is taking seriously. We are listening and will adjust our approach based on what we learn in relationship with key partners.
10. We know that increased training is just one piece of the puzzle.
    The CFPC is advocating for significant changes to address the many issues facing family physicians and family medicine and will be sharing more information about its advocacy and actions in the coming weeks.

Curricular changes will have a renewed emphasis on training for full scope (comprehensive) training now clearly defined by the CFPC’s Residency Training Profile based on the Family Medicine Professional Profile and made possible with longer training.
Specifically:

• More training in areas of societal need such as home and long-term care, mental health and addiction, Indigenous health, cultural safety and trauma-informed care, anti-racism, virtual care, and health informatics.
• Greater emphasis on the development of adaptive expertise as essential to the preparation for generalist practice, to the ability to respond to changing community needs, and to manage the high level of complexity and medical uncertainty inherent to family practice.
• Enhancements to support family physicians’ increasing involvement in health system leadership, population and public health, and practice improvement particularly for underserved communities.
• More opportunities to train and then practice in evidence-based, interdependent, team care visions like the Patient’s Medical Home (PMH).
• Clarified expectations for enhanced skills training programs leading to a Certificate of Added Competence (CAC) with a greater emphasis on development of health system leadership and support for comprehensive primary care integrated within PMH-type care visions.
• A longer training period (increase from two to three years) is required to support the necessary curricular enhancements.

Family physicians are being called on to manage increasingly complex health care and social needs as well as an aging population with multiple health issues. The training of family physicians must keep pace with these changes. The COVID-19 pandemic highlights current inequities and fragmentation in the health system. It is essential that the health system be reorganized to support fully integrated team-based practice models as described in the Patient’s Medical Home vision to ensure coordination of care and support for primary care practitioners. Training must be better aligned with and supportive of reformed care models. The federal government has pledged that every Canadian will have access to a family physician/primary care team. Education reform must be linked with health system reform to achieve this goal. A greater investment in training family physicians is an important part of the effort to ensure equitable and timely access to comprehensive care for people in Canada. Evidence tells us that our graduates have a strong preference for group/team-based practices like the PMH, yet are frustrated in not having access to these on graduation. It is critical and timely to bring about health system reform linked with education reform to recruit and retain family physicians and achieve health workforce goals.
 

We will work closely with our university partners on implementing these recommendations and strike an Education Reform Taskforce to help us guide this change. The CFPC will introduce changes to its residency accreditation standards in five years (2027) to allow for a responsible change engagement approach including the resources needed to support the change. We will work closely with our provincial Chapters and university partners to advocate with federal and provincial governments to support the recommendations to enhance the delivery of family medicine for all the people of Canada.