Right from the start, Lara Doyle-Trace, a fourth-year medical student at McGill University, loved everything about medical school, especially pediatrics and obstetrics. But the thought of having to choose between the two left her torn.
Fourth-year McGill medical student Lara Doyle-Trace at Montreal's Royal Victoria Hospital. Photo: John Morstad for The Globe and Mail
Fourth-year McGill medical student Lara Doyle-Trace at Montreal's Royal Victoria Hospital. Photo: John Morstad for The Globe and Mail
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It wasn't until she did a stint in family medicine training toward the end of her third year that the pieces fell into place. Her training took her to a remote Cree village on the shores of James Bay and to Hawkesbury, a small town midway between Ottawa and Montreal, where she worked alongside family doctors delivering babies, doing well-baby visits and providing a host of other services.
"I realized that this was perfect for me," she says, her voice brimming with enthusiasm. "I absolutely loved the variety and the challenge of it. . . I definitely want to be the type of doctor that gets to do everything."
It isn't just Ms. Doyle-Trace. An increasing number of students are opting to pursue careers in family medicine, thanks in large part to measures implemented by medical schools in recent years. In 2009, 32.5 per cent of medical graduates opted to do a residency in family medicine, up from 24.8 per cent in 2003, the year it hit an all-time low. But, that's still significantly below where it stood in the early 1990s.
What happened in 2003 "was a huge wake-up call" for medical schools across the country, says Cathy MacLean, head of the family medicine department at the University of Calgary and president of the College of Family Physicians of Canada. It led them to take a hard look at what was causing students to turn their backs on family medicine.
To be sure, the disparity in salaries earned by family doctors and specialists was an issue. But there were other troubling factors at play. For one thing, family doctors were virtually absent from medical schools. Most of the courses were taught by specialists and much of the hands-on medical training took place in large, urban teaching hospitals where specialists practice. Some of the cases used in problem-based learning tended to portray family doctors as those who simply referred cases to specialists, Dr. MacLean says. And family medicine had shorter clerkships than other specialties.
Then there was the issue of what medical schools refer to as "the hidden curriculum;" spoken and unspoken suggestions that family medicine is somehow a second-rate option to the more-highly esteemed specialties and best suited for those who can't cut it in one of the specialties. "Even when I went through medical school, if you said you wanted to do family medicine, it wasn't uncommon to hear, 'Oh you're not going to be just a GP,'" Dr. MacLean says.
Realizing the need for action, medical schools implemented a number of measures to raise the profile of family medicine. Among other things, they increased the length of family medicine clerkships and boosted the presence of family doctors in medical schools.
The University of Calgary established a task force to recommend ways of promoting family medicine as a career choice. The university hired more family doctors to fill teaching and administrative positions and it increased the term of the family medicine clerkship to six weeks from four. It also changed the undergraduate curriculum to start exposing students to family medicine right from first year. The measures seem to be working. The proportion of medical graduates who chose family medicine increased to 26 per cent in 2009 from 18 per cent in 2007. The schools aims to increase the figure to 50 per cent.
At the University of Western Ontario, the percentage of medical graduates who went on to do a family medicine residency rose to an all time high of 45 per cent in 2009, up from 31 per cent in 2008; an increase that Carol Herbert, dean of Western's Schulich School of Medicine and Dentistry calls "very gratifying."
To achieve these results, she says the school's faculty started openly discussing with students the societal need for more family doctors. The school also increased the visibility of its family doctors, locating their offices more centrally and getting them to do more of the teaching, especially at the undergraduate level. "It lets people see family doctors in action and then they can imagine themselves being family doctors," Dr. Herbert says.
Western, Calgary and many other medical schools instituted Family Medicine Interest Groups, support groups for family medicine students that arrange for speakers, hold workshops and host social events.
McGill University increased its family medicine clerkship to eight weeks from four. And it recently held a summit for medical students to showcase research being done in family medicine and dispel some myths. "Some of the students have the impression that it isn't a very academic career," says Martin Dawes, chair of McGill's department of family medicine. "Some of them have the impression that you can't do research as a family physician or that you can't specialize."
Other factors have also contributed to the renewed interest in family medicine. Compensation for family doctors has improved in some provinces and, although specialists still earn more, the gap between the two has narrowed. Also, more doctors are working in groups, which provide a more supportive working environment. In Ontario, for instance, the introduction of family health teams, which group family doctors with nurse practitioners, pharmacists and specialists, and changes to payment methods has made family medicine more attractive. "I think the general happiness of family physicians has improved over the last few years as governments have recognized the importance of primary care and that's filtered down to medical students," says Ian Scott, undergraduate director of family medicine at the University of British Columbia, who researches issues in medical education.
These factors, along with changes to medical school curriculums, are clearly having an impact. The proportion of Canadians without a family doctor has decreased to about 12 per cent of the population from a previously estimated 17 per cent, according to the College of Family Physicians of Canada. Still, that's four million Canadians without access to primary medical care. And Canada still has fewer doctors per capita than many other countries, Dr. Scott notes.
According to one estimate, an additional 3,000 family doctors are needed, he adds. Plus a large group of older doctors are nearing retirement and the younger ones replacing them generally aren't willing to work the long hours their predecessors did, he says.
So while medical schools have good reason to cheer their progress, Dr. Scott cautions that they should remain vigilant that there isn't a return to the days in the early part of the decade when the number of students choosing family practice was on the wane.
"I'm encouraged now," he says. "I say to students that this is a great time for family practice." But, he warns, "The pendulum could swing back again."
Special to The Globe and Mail
