FM residency should be shortened to two years like in Canada

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deleted547631

I don't see people dying en masse over there due to their primary care FM doctors not having a half a year of electives during residency. It would go along way to alleviate the primary care doctor shortage due to a quicker and more efficient training pathway.

Also, Canada allows its 24-month in length residency trained Family Medicine doctors to pursue a one year fellowship in Emergency Medicine to become, effectively, emergency medicine doctors.

Why can't we have good things?
 
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Still a med student but going into FM

Most of the FM residents I know used that elective time to gain more experience in stuff they needed to know for the jobs they had accepted. E.g. if they had taken a job where they would be rounding on their patients in the hospital, they did a couple extra months of inpatient and maybe ICU. If their job needed someone to do more sports medicine, they did an extra sports med or ortho rotation to get more experienced with joint injections and that sort of thing. Some also use those months to do "away" rotations at clinics where they're considering accepting a job. Are these things absolutely necessary to provide high quality bread and butter outpatient primary care? Probably not. But the residents I've spoken to appreciate having that time, and it's especially valuable for those who are going to have a bit broader scope of practice.

Also, decreasing the length of training would not increase the number of PCPs in the community or alleviate the shortage at all. There will still be the same number of residency spots and therefore the same number of new FM docs graduating every year. They will still concentrate in the same areas they always have. And I don't know any med students who are thinking "jeez, I'd love to do FM if only it were 2 years instead of 3," so I don't think length of training will suddenly draw more people into a specialty they don't enjoy for various reasons.
 
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Academicians and administrative types have always pushed for increased length of training. If competency milestones are achieved in two years, just make third year optional? The doc in the 2012 article is supportive of the push in the US to increase FM to a four-year residency. Case in point!
 
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Also, decreasing the length of training would not increase the number of PCPs in the community or alleviate the shortage at all. There will still be the same number of residency spots and therefore the same number of new FM docs graduating every year. They will still concentrate in the same areas they always have. And I don't know any med students who are thinking "jeez, I'd love to do FM if only it were 2 years instead of 3," so I don't think length of training will suddenly draw more people into a specialty they don't enjoy for various reasons.

Over a 10 year period, there would be 33% more residency trained FM doctors in a two-year model (i.e. Canada) versus the current three-year (i.e. USA). How would more numbers not at least help if the added capacity would push doctors into jobs into ‘non-desirable’ places? Supply and demand.

I know a lot of Med students going for FM who’d wish there was a reduction of time in training. Example: NYU’s three-year accelerated MD for people going into primary care.
 
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Over a 10 year period, there would be 33% more residency trained FM doctors in a two-year model (i.e. Canada) versus the current three-year (i.e. USA). How would more numbers not at least help if the added capacity would push doctors into jobs into ‘non-desirable’ places? Supply and demand.
There would be an initial influx of people who would have graduated the next year anyway - essentially two classes graduating at the same time - and then it would go back to the same number of people graduating every year. Maybe I'm just not getting it, in which case please explain to me what I'm missing - what's your source for the 33% figure? But this doesn't seem like a long term solution without opening up more residency positions.

I know a lot of Med students going for FM who’d wish there was a reduction of time in training. Example: NYU’s three-year accelerated MD for people going into primary care.
Key words: "med students going for FM." Yes, it would be convenient for people who are already planning on doing FM, but I'm not convinced that reducing the length of training will encourage more people to do FM who were not already considering it, which is what would be required to actually increase the number of FM doctors (in addition to an increase in the number of residency positions). As I said, there are many, many reasons that people aren't interested in FM, and I don't think having 3 years of training instead of 2 is one of them.
 
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Key words: "med students going for FM." Yes, it would be convenient for people who are already planning on doing FM, but I'm not convinced that reducing the length of training will encourage more people to do FM who were not already considering it, which is what would be required to actually increase the number of FM doctors (in addition to an increase in the number of residency positions). As I said, there are many, many reasons that people aren't interested in FM, and I don't think having 3 years of training instead of 2 is one of them.

Specialty selection is multifactorial and training time is an important factor that’s held into account in specialty selection process, I’d say. I’d be further swayed to go for FM over IM if it was a year shorter all things considered, n=1. Of course, preference of specialty trumps residency training time.

Academic medicine keeps pushing for lengthier residencies, this just makes the American healthcare system less efficient overall. PA school is 27 months long and can work in primary care independently on Day 1.
 
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Specialty selection is multifactorial and training time is an important factor that’s held into account in specialty selection process, I’d say. I’d be further swayed to go for FM over IM if it was a year shorter all things considered, n=1. Of course, preference of specialty trumps residency training time.
Most people I know who were debating IM/FM were more concerned about ability to specialize, not wanting to do OB and/or peds, and wanting to do hospitalist work rather than training time. I'm sure there are some people out there who care more about residency length than those factors but it hasn't been my experience that this mindset is common.

ETA: And regardless, even if it were true that a bunch of people would suddenly flock to FM if it were a 2 year program, there are still only so many residency slots and so the number of people graduating each year would remain constant.

Academic medicine keeps pushing for lengthier residencies, this just makes the American healthcare system less efficient overall.
Sure, but I'm not sure that reducing (vs just not increasing) the length of training for specialties that (1) already have the shortest training time and (2) arguably need a broader base of knowledge and skills than most specialties is the right place to start this crusade.

PA school is 27 months long and can work in primary care independently on Day 1.
And I think many on this website would argue that this shouldn't be the case. Also worth noting that it's not usually "independently" on day 1, there's usually a period of training and oversight before their physician supervisor allows them to just do whatever they want.
 
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Most people I know who were debating IM/FM were more concerned about ability to specialize, not wanting to do OB and/or peds, and wanting to do hospitalist work rather than training time. I'm sure there are some people out there who care more about residency length than those factors but it hasn't been my experience that this mindset is common.

ETA: And regardless, even if it were true that a bunch of people would suddenly flock to FM if it were a 2 year program, there are still only so many residency slots and so the number of people graduating each year would remain constant.


Sure, but I'm not sure that reducing (vs just not increasing) the length of training for specialties that (1) already have the shortest training time and (2) arguably need a broader base of knowledge and skills than most specialties is the right place to start this crusade.


And I think many on this website would argue that this shouldn't be the case. Also worth noting that it's not usually "independently" on day 1, there's usually a period of training and oversight before their physician supervisor allows them to just do whatever they want.
Yeah I'm really not getting this math part.

There are only so many FM spots/year. Even if we go from 3 years to 2, its the same number of spots/year that would graduate other than that first year and the roughly 3.5k extra docs for one year wouldn't make a bit of difference.
 
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MOHS_01

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Yeah I'm really not getting this math part.

There are only so many FM spots/year. Even if we go from 3 years to 2, its the same number of spots/year that would graduate other than that first year and the roughly 3.5k extra docs for one year wouldn't make a bit of difference.

I believe the increase in FP training comes from the reallocation of that third year of funding into additional first and second year spots, essentially increasing the number of trainees for dollars by 1/3. In equilibrium dynamics, assuming the system is anywhere near the equilibrium point, this would represent a massive disruption in only a few years.

In short, if I was an FP, IM, or Peds Doc, I’d fight this tooth and nail.


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I believe the increase in FP training comes from the reallocation of that third year of funding into additional first and second year spots, essentially increasing the number of trainees for dollars by 1/3. In equilibrium dynamics, assuming the system is anywhere near the equilibrium point, this would represent a massive disruption in only a few years.

Yes! This is what I mean and should’ve clarified. The assumption is that the removed PGY3 funding would go to more training spots, increasing supply.
 
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Yes! This is what I mean and should’ve clarified. The assumption is that the removed PGY3 funding would go to more training spots, increasing supply.

But, as has already been mentioned, there are already unfilled positions each year.

"Y'know, I'd have gone into FM, but three years is just too long a residency." Said no one, ever.
 
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Yes! This is what I mean and should’ve clarified. The assumption is that the removed PGY3 funding would go to more training spots, increasing supply.

Yeah but then you didn't reply to the very last part: "In short, if I was an FP, IM, or Peds Doc, I’d fight this tooth and nail."

I have been pretty solidly FM since being a premed. Now that I'm in 3rd year that's really not changing, even despite specialties joking/not really joking that FM isn't the brightest bulb in the medicine bunch. While I'm not arguing for MORE time as a resident, the idea of my residency being cut short by a year to become the shortest of all of them really DOES NOT appeal to me. Why?

1. I would rather have an extra year to round out my knowledge base before jumping in, even if I am sure residency gets old at that point. My goal is to be a general practitioner with a reasonable pool of knowledge in most topics/things I found interest in, not whatever could be fit into 2 years.

2. Other specialties already rip on FM as is. I don't need to hear more crap based on, "Yeah, but they only have a 2yr residency. How much do they REALLY know about medicine?"

3. As someone has already said, the problem is not residency slots--it's people that WANT the residency slot. Look at the 2018 match data for FM compared to 2017: Family Medicine 2018 National Resident Matching Program (NRMP) Results Analysis
  • Offered 276 more positions than 2017 (3,654 vs. 3,378)
  • Matched 298 more students and graduates (3,535 vs. 3,237)
  • Matched 118 more U.S. MD seniors (1,648 vs. 1,530)
  • Matched 125 more osteopathic medical students or graduates (701 vs. 576)
  • Had a slight increase in overall fill rate year-over-year (96.7% vs. 95.8%), marking the highest fill rate in the specialty’s history
  • Had a similar fill rate for U.S. MD seniors (45.1% vs. 45.3%)
  • Had an increase in fill rate for osteopathic medical students and graduates (19.2% vs. 17.0%)
  • Offered 12.0% of all positions in the Match (11.7% in 2017)
  • Matched 9.3% of all U.S. MD seniors in the Match (8.8% in 2017)
  • Matched 18.6% of all DO students and graduates in the Match
The problem isn't the slot numbers because those are still increasing as demand increases. The problem is that the fill rate for those slots is still not 100%. Why make an argument for quantity OVER quality of the residency when we still haven't reached capacity via traditional residencies?

4. Why make a move that will draw more applicants who say, "Well screw it, I couldn't get into ___ so I may as well do FM, it's only 2yrs after all..." while alienating those that say "I was going to do FM, but I don't think 2yrs is enough training so I'll shoot for ___."
 
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VA Hopeful Dr

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I believe the increase in FP training comes from the reallocation of that third year of funding into additional first and second year spots, essentially increasing the number of trainees for dollars by 1/3. In equilibrium dynamics, assuming the system is anywhere near the equilibrium point, this would represent a massive disruption in only a few years.

In short, if I was an FP, IM, or Peds Doc, I’d fight this tooth and nail.


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Not sure that would work. There are only so many patients, it would require a complete overhaul of the curriculum at most places.

I also can't remember ever hearing someone say that they had too much training.
 
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Yes! This is what I mean and should’ve clarified. The assumption is that the removed PGY3 funding would go to more training spots, increasing supply.
Ah, got it, this makes more sense. Assuming that we can trust the federal government to allocate that funding appropriately lol.

How would more numbers not at least help if the added capacity would push doctors into jobs into ‘non-desirable’ places? Supply and demand.
So now we're pushing doctors with less training into 'non-desirable' places, which tend to be underserved and if anything require an even broader skill set, knowledge base, and scope of practice. I'd argue that doctors in those places benefit the most from the third year of training as I discussed in my first post.

this just makes the American healthcare system less efficient overall.
Re: your point on efficiency:
1) I'd be curious to see data on whether FM docs with 2 years of training instead of 3 are more likely to refer to specialists for things that could potentially be managed in a PCP's office.
2) You'd probably also get less FM docs doing inpatient medicine, staffing EDs, providing OB care, etc. in areas where those services are needed. Which means:
-Continuity of care is going to take a hit, probably reducing efficiency to an extent.
-Either more IM, EM, and OBGYN docs will have to be recruited to rural/underserved areas to compensate, or those services will just become less available in rural communities, worsening the health of rural patients and leading to increased healthcare costs.
 
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Yeah but then you didn't reply to the very last part: "In short, if I was an FP, IM, or Peds Doc, I’d fight this tooth and nail."

I have been pretty solidly FM since being a premed. Now that I'm in 3rd year that's really not changing, even despite specialties joking/not really joking that FM isn't the brightest bulb in the medicine bunch. While I'm not arguing for MORE time as a resident, the idea of my residency being cut short by a year to become the shortest of all of them really DOES NOT appeal to me. Why?

1. I would rather have an extra year to round out my knowledge base before jumping in, even if I am sure residency gets old at that point. My goal is to be a general practitioner with a reasonable pool of knowledge in most topics/things I found interest in, not whatever could be fit into 2 years.

2. Other specialties already rip on FM as is. I don't need to hear more crap based on, "Yeah, but they only have a 2yr residency. How much do they REALLY know about medicine?"

3. As someone has already said, the problem is not residency slots--it's people that WANT the residency slot. Look at the 2018 match data for FM compared to 2017: Family Medicine 2018 National Resident Matching Program (NRMP) Results Analysis
  • Offered 276 more positions than 2017 (3,654 vs. 3,378)
  • Matched 298 more students and graduates (3,535 vs. 3,237)
  • Matched 118 more U.S. MD seniors (1,648 vs. 1,530)
  • Matched 125 more osteopathic medical students or graduates (701 vs. 576)
  • Had a slight increase in overall fill rate year-over-year (96.7% vs. 95.8%), marking the highest fill rate in the specialty’s history
  • Had a similar fill rate for U.S. MD seniors (45.1% vs. 45.3%)
  • Had an increase in fill rate for osteopathic medical students and graduates (19.2% vs. 17.0%)
  • Offered 12.0% of all positions in the Match (11.7% in 2017)
  • Matched 9.3% of all U.S. MD seniors in the Match (8.8% in 2017)
  • Matched 18.6% of all DO students and graduates in the Match
The problem isn't the slot numbers because those are still increasing as demand increases. The problem is that the fill rate for those slots is still not 100%. Why make an argument for quantity OVER quality of the residency when we still haven't reached capacity via traditional residencies?

4. Why make a move that will draw more applicants who say, "Well screw it, I couldn't get into ___ so I may as well do FM, it's only 2yrs after all..." while alienating those that say "I was going to do FM, but I don't think 2yrs is enough training so I'll shoot for ___."

Well reasoned post, I appreciate your reply.

I guess the two points I’d like to make still stand, however.

1) wouldn’t more expedient training alleviate the projected 90,000 primary care physician shortage?

2) are Canadian two-year trained FM docs not up to par with US three-year trains FM docs? They seem to be doing fine with one less year of residency.
 
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Well reasoned post, I appreciate your reply.

I guess the two points I’d like to make still stand, however.

1) wouldn’t more expedient training alleviate the projected 90,000 primary care physician shortage?

2) are Canadian two-year trained FM docs not up to par with US three-year trains FM docs? They seem to be doing fine with one less year of residency.

Regarding #1, I'd say there are other ways of doing that without reinventing the wheel:
- Make loan forgiveness a priority so the false argument that FM docs won't make enough to pay off loans and live comfortably goes away for good
- Keep pumping up primary care pay for docs. Can't say I know where you're from or where you wanna practice, but for me in the midwest I am VERY excited for some of the offers people fresh out of residency have been seeing for the past decade or so. It's going up!
- Instead of changing residency, change school! I haven't looked at the data, but there are already 3yr MD/DO programs that skip 4th year by focusing their curriculum on primary care only. If someone knows they're going into FM, cut their debt and time in school and let them get to residency faster

As for #2, I could pretend I know anything about the topic and speak out of my butt, but I won't waste anyone's time with that. It's a good question and perhaps someone else could respond.
 

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Not sure that would work. There are only so many patients, it would require a complete overhaul of the curriculum at most places.

I also can't remember ever hearing someone say that they had too much training.
I'm not saying it's a good idea -- I'm just restating that portion of the argument. This is not a terribly novel idea, by the way; I have a couple of referrings and one friend who managed to combine their fourth year of medical school with their intern year, as I understand it, as part of some "fast track" primary care internal medicine residency -- way back in 2002.
 

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It might be better to make med school a 6-yr endeavor. 3 years prereqs + 3 years med school. Not advocating med school directly from high school.
 

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Not sure that would work. There are only so many patients, it would require a complete overhaul of the curriculum at most places.

I also can't remember ever hearing someone say that they had too much training.
How much is enough?
 

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I'm not saying it's a good idea -- I'm just restating that portion of the argument. This is not a terribly novel idea, by the way; I have a couple of referrings and one friend who managed to combine their fourth year of medical school with their intern year, as I understand it, as part of some "fast track" primary care internal medicine residency -- way back in 2002.
Yeah I've heard of that in certain places. I have a hard time objecting to that one - though the places that do it now basically graduate you in 3 years from med school and you still do the full residency.
 
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I think you could easily pull a year from medical school and not lose anything. Plenty of schools do preclinicals in one year, with a research year in place of what would be the second year of preclinicals. You could also probably lose some of the end of M4 rotations that take place after match lists are certified and people are coasting.
 

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The idea of pgy-2s supervising interns is kind of hilarious.

And how about doing job interviews as an intern?

Poor attendings would functionally become pgy-3s. :lol:

I think the 3 year model is perfect. pgy-1 get heavily worked, scrutinized, taught, chewed-out, etc, Pgy-2 rotate through specialties, do solo med and OB night float. Pgy-3 You do the scrutinizing, teaching, chewing-out, etc. I think you have to do all 3 stages.
 

VA Hopeful Dr

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The idea of pgy-2s supervising interns is kind of hilarious.

And how about doing job interviews as an intern?

Poor attendings would functionally become pgy-3s. :lol:

I think the 3 year model is perfect. pgy-1 get heavily worked, scrutinized, taught, chewed-out, etc, Pgy-2 rotate through specialties, do solo med and OB night float. Pgy-3 You do the scrutinizing, teaching, chewing-out, etc. I think you have to do all 3 stages.
That and the old saying, if it ain't broke...
 

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The idea of pgy-2s supervising interns is kind of hilarious.

And how about doing job interviews as an intern?

Poor attendings would functionally become pgy-3s. :lol:

I think the 3 year model is perfect. pgy-1 get heavily worked, scrutinized, taught, chewed-out, etc, Pgy-2 rotate through specialties, do solo med and OB night float. Pgy-3 You do the scrutinizing, teaching, chewing-out, etc. I think you have to do all 3 stages.

My program had 2nd years supervising and teaching interns. And I interviewed for my current job when I was an intern too...

Not saying I think FM should be a 2 year program, I don’t. But you really didn’t run an inpatient service, or run the OB service as a PGY2?
 
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VA Hopeful Dr

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My program had 2nd years supervising and teaching interns. And I interviewed for my current job when I was an intern too...

Not saying I think FM should be a 2 year program, I don’t. But you really didn’t run an inpatient service, or run the OB service as a PGY2?
Mine as well, but not until the second half of 2nd year and then only night float.

We had 1 person interview for jobs as an intern but it was what you'd expect - super rural, desperate enough to give a monthly stipend if you agreed to work there.
 
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Kind of in a unique position here, having done 1 year of FM residency in canada prior to moving to the US and completing IM residency (community program) here.

i did my fm year at a community site of a university program. We had continuity clinic once a week, but also spent about 4 months of the first year in our clinic, the other 8 months doing IM, OB, and Peds, and ER. Our second year would have been mostly electives with lots of clinic time. Fyi Most fm docs in canada do not do hospitalist work, few do an additional year of training (er, ob, palliative etc) but do full outpatient primary care. Also keep in mind that canadians use primary care more appropriatley, and see their pcp often.

By the end of my first year, i felt comfortable with the majority of primary care bread and butter - well visits, immunizations, rashes, flu season, htn and dm management, prenatal care, etc for routine patients. My attendings were awesome educators and really taught me a lot. The second year would have consolidated my learning, helped me advance my learning in areas like cardio, endocrine etc. at the end of my first year i felt that with another year of training i would be safe to do routine primary care in a suburban environment where everyone had access to primary care (universal insurance) and used it frequently. I would not have been comfortable going to a rural area where I would be the only doc available for miles

My intern year in IM residency was not helpful in terms of my ability to practice as a primary care doctor. If anything i think i lost skills in this area! The awful set up of the clinic, the lack of true continuity with the entire intern year schedule, and the range of undifferentiated symptoms in a popultation who infrequently followed up/took their meds as prescribed/ or had the means to seek additional care made primary in the IM resident clinic so disheartening, yet isnt it is the truth about most primary care in US?

I learned a lot about inpatient medicine that year, and if those types of experiences were the same as my fm peers, then I can see how 2 years would not be enough - even in 2'nd year electives were mostly with inpatient or too specialty focused, not enough clinic exposure, etc - which makes perfect sense if you are going to specialize or do inpatient only, not if u want to do primary care. When i was in my third year of IM i got to do more primary care clinic, and really began to feel the love again for primary care. Of course at this point i had accepted a fellowship spot in HPM.

Tldr: in suburban canada where people use their primary care appropriatley, 2 years is more than enough to be an adequate pcp - provided you continue to grow and learn.The demands of a pcp in the US who work in more rural or areas of lower socioeconomic resources are higher, in my opinion, and feeling comfortable taking care of this population takes more time.
 

VA Hopeful Dr

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Kind of in a unique position here, having done 1 year of FM residency in canada prior to moving to the US and completing IM residency (community program) here.

i did my fm year at a community site of a university program. We had continuity clinic once a week, but also spent about 4 months of the first year in our clinic, the other 8 months doing IM, OB, and Peds, and ER. Our second year would have been mostly electives with lots of clinic time. Fyi Most fm docs in canada do not do hospitalist work, few do an additional year of training (er, ob, palliative etc) but do full outpatient primary care. Also keep in mind that canadians use primary care more appropriatley, and see their pcp often.

By the end of my first year, i felt comfortable with the majority of primary care bread and butter - well visits, immunizations, rashes, flu season, htn and dm management, prenatal care, etc for routine patients. My attendings were awesome educators and really taught me a lot. The second year would have consolidated my learning, helped me advance my learning in areas like cardio, endocrine etc. at the end of my first year i felt that with another year of training i would be safe to do routine primary care in a suburban environment where everyone had access to primary care (universal insurance) and used it frequently. I would not have been comfortable going to a rural area where I would be the only doc available for miles

My intern year in IM residency was not helpful in terms of my ability to practice as a primary care doctor. If anything i think i lost skills in this area! The awful set up of the clinic, the lack of true continuity with the entire intern year schedule, and the range of undifferentiated symptoms in a popultation who infrequently followed up/took their meds as prescribed/ or had the means to seek additional care made primary in the IM resident clinic so disheartening, yet isnt it is the truth about most primary care in US?

I learned a lot about inpatient medicine that year, and if those types of experiences were the same as my fm peers, then I can see how 2 years would not be enough - even in 2'nd year electives were mostly with inpatient or too specialty focused, not enough clinic exposure, etc - which makes perfect sense if you are going to specialize or do inpatient only, not if u want to do primary care. When i was in my third year of IM i got to do more primary care clinic, and really began to feel the love again for primary care. Of course at this point i had accepted a fellowship spot in HPM.

Tldr: in suburban canada where people use their primary care appropriatley, 2 years is more than enough to be an adequate pcp - provided you continue to grow and learn.The demands of a pcp in the US who work in more rural or areas of lower socioeconomic resources are higher, in my opinion, and feeling comfortable taking care of this population takes more time.

Huh, its almost like Canada is different from the US, eh @Lexdiamondz
 

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Mine as well, but not until the second half of 2nd year and then only night float.

We had 1 person interview for jobs as an intern but it was what you'd expect - super rural, desperate enough to give a monthly stipend if you agreed to work there.

Sounds appropriate. We were expected to be senior resident in medicine and OB from day 1 of 2nd year. I did medicine in Sept, but a Coresident went from medicine intern directly to medicine senior for the next block.
 

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Sounds appropriate. We were expected to be senior resident in medicine and OB from day 1 of 2nd year. I did medicine in Sept, but a Coresident went from medicine intern directly to medicine senior for the next block.
I went from senior resident supervising an intern on night float over Thanksgiving back to working equal to the interns under a 3rd year at Christmas (schedule was weird that year as the 2011 work hours rules were implemented).
 
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Well reasoned post, I appreciate your reply.

I guess the two points I’d like to make still stand, however.

1) wouldn’t more expedient training alleviate the projected 90,000 primary care physician shortage?

2) are Canadian two-year trained FM docs not up to par with US three-year trains FM docs? They seem to be doing fine with one less year of residency.
Regarding #1, I'd say there are other ways of doing that without reinventing the wheel:
- Make loan forgiveness a priority so the false argument that FM docs won't make enough to pay off loans and live comfortably goes away for good
- Keep pumping up primary care pay for docs. Can't say I know where you're from or where you wanna practice, but for me in the midwest I am VERY excited for some of the offers people fresh out of residency have been seeing for the past decade or so. It's going up!
- Instead of changing residency, change school! I haven't looked at the data, but there are already 3yr MD/DO programs that skip 4th year by focusing their curriculum on primary care only. If someone knows they're going into FM, cut their debt and time in school and let them get to residency faster

As for #2, I could pretend I know anything about the topic and speak out of my butt, but I won't waste anyone's time with that. It's a good question and perhaps someone else could respond.

Huh, its almost like Canada is different from the US, eh @Lexdiamondz

Canadian med schools also use MS3s and MS4s similar to PGY1s in USA. They're able to manage bread and butter patients with baseline competency vs USA students who know every zebra in the book but can spend half of ms3-ms4 just shadowing on rotations and therefore lack practical skills/knowledge.

You can get away with a shorter training duration when everyone's starting point is a bit higher.

Also, 3 years of residency in USA - but what portion of that is shadowing (specialty rotations)? My understanding is that shadowing does not exist as a concept in medical education or residency training in Canada. If you're on a rotation, you're always actively working - even with a specialist's private patients. Whereas in USA, it's quite common to shadow in those settings.
 
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Why hasn't anyone brought up the point of being a well rounded FM doc with US training? I.e. peds through geri, in-patient to outpatient, non-surgical OB (+/- that too if fellowship trained), ED as well. We receive adequate training to manage all of these, I can't say the same about PCP's from Canada who are doing outpatient only peds-geri, no ob, no ED, no inpatient either. Perhaps this is more forgiving w/ Canadian patients as I see them as "healthier", secondary to having socialized medicine.

Now critics will say, well, did you learn all that in a year? No, but its the longitudinal aspect of 3 years where you manage your panel of patients, in these different settings for 3 years vs. 1 year (2nd being electives year) in Canada.
 
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Kind of in a unique position here, having done 1 year of FM residency in canada prior to moving to the US and completing IM residency (community program) here.

i did my fm year at a community site of a university program. We had continuity clinic once a week, but also spent about 4 months of the first year in our clinic, the other 8 months doing IM, OB, and Peds, and ER. Our second year would have been mostly electives with lots of clinic time. Fyi Most fm docs in canada do not do hospitalist work, few do an additional year of training (er, ob, palliative etc) but do full outpatient primary care. Also keep in mind that canadians use primary care more appropriatley, and see their pcp often.
...
Tldr: in suburban canada where people use their primary care appropriatley, 2 years is more than enough to be an adequate pcp - provided you continue to grow and learn. The demands of a pcp in the US who work in more rural or areas of lower socioeconomic resources are higher, in my opinion, and feeling comfortable taking care of this population takes more time.

Why hasn't anyone brought up the point of being a well rounded FM doc with US training? I.e. peds through geri, in-patient to outpatient, non-surgical OB (+/- that too if fellowship trained), ED as well. We receive adequate training to manage all of these, I can't say the same about PCP's from Canada who are doing outpatient only peds-geri, no ob, no ED, no inpatient either. Perhaps this is more forgiving w/ Canadian patients as I see them as "healthier", secondary to having socialized medicine.

I feel like geripalgal partially touched on the issue, though not as directly from a US FM side as yourself. Your points seem to line up with each other, I think. Very interesting to see both sides of the trenches from people working in 'em.
 
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Canadian med schools also use MS3s and MS4s similar to PGY1s in USA. They're able to manage bread and butter patients with baseline competency vs USA students who know every zebra in the book but can spend half of ms3-ms4 just shadowing on rotations and therefore lack practical skills/knowledge.

You can get away with a shorter training duration when everyone's starting point is a bit higher.

Also, 3 years of residency in USA - but what portion of that is shadowing (specialty rotations)? My understanding is that shadowing does not exist as a concept in medical education or residency training in Canada. If you're on a rotation, you're always actively working - even with a specialist's private patients. Whereas in USA, it's quite common to shadow in those settings.



The part about clerkship in canada is true, we did more than the students ive seen do here... I overall felt very prepared for internship and Ive been amazed at how little interns knew at the begining of the year here. But we all learn to swim (or sink) eventually

However, my YEAR of canadian fm residency did not prepare me for (the horrors of) IM resident clinic.... even established patients to the clinic needed a full comprehensive plan to be reinvented because they hadnt followed up / or followed through with prior recommendations for months - it was essentially a new patient visit all over again!! A 4 hour clinic half day was so mentally exhausting - i would rather do a shift of icu or admissions or even night-float as a senior (but never ever again intern nightfloat)

its hard to learn (or practice) good primary care without the continuity.... and really creates a lot of disatisfaction. Its not surprising to me at all that none of my coresidents pursued primary care - even I who loved FM chose to stay away.

Primary care in the US is a different beast entirely - not because the medicine is different - but because of the population and how it is utilized by the population (not to mention the complexities of insurance/ pre-auth, paperwork, billing, and fear of litigation /need to practice defensive medicine - which are all far simpler in canada).
 
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The part about clerkship in canada is true, we did more than the students ive seen do here... I overall felt very prepared for internship and Ive been amazed at how little interns knew at the begining of the year here. But we all learn to swim (or sink) eventually

However, my YEAR of canadian fm residency did not prepare me for (the horrors of) IM resident clinic.... even established patients to the clinic needed a full comprehensive plan to be reinvented because they hadnt followed up / or followed through with prior recommendations for months - it was essentially a new patient visit all over again!! A 4 hour clinic half day was so mentally exhausting - i would rather do a shift of icu or admissions or even night-float as a senior (but never ever again intern nightfloat)

its hard to learn (or practice) good primary care without the continuity.... and really creates a lot of disatisfaction. Its not surprising to me at all that none of my coresidents pursued primary care - even I who loved FM chose to stay away.

Primary care in the US is a different beast entirely - not because the medicine is different - but because of the population and how it is utilized by the population (not to mention the complexities of insurance/ pre-auth, paperwork, billing, and fear of litigation /need to practice defensive medicine - which are all far simpler in canada).

True. Out of curiosity, since I don't know details, any specific differences you noticed between a typical PGY1 in Canada vs in USA? Largely tracing back to clerkship similarities & differences. I mean are there any examples you can think of?
It's interesting to know, given the cost of tuition in USA.
 

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It would be more feasible to shorten med school to 3 years (18 months + 18 months). Get rid of the facto requirement of a baccalaureate degree. Just ask for prereqs and English.
 
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True. Out of curiosity, since I don't know details, any specific differences you noticed between a typical PGY1 in Canada vs in USA? Largely tracing back to clerkship similarities & differences. I mean are there any examples you can think of?
It's interesting to know, given the cost of tuition in USA.

During my medicine clerkship we were treated like an intern on the team. We had our own (upto 2 patients) that we wrote notes on, reviewed and presented to attending with the teams senior as backup. We participted in rounds, education etc - this is similar to ms3s here

What was different:
. There were 5 medicine teams, everynight each team had an intern oncall 1 senior wouldbe on call for all of medicine (so 5 interns, 1 senior). On call you took care of your team, attended codes, and did a lot of admissions. The medical students were part of the rotation, but were only scheduled on nights their teams senior was on call (so max 1 student overnight). So i took overnight call, roughly every 5 nights where I took first call for my team. Orders were still paperbased - i could write orders and get them cosigned by my resident.

so I learned how to write complete admission orders, i learned how to write for a sliding scale, treat DKA, workup new anemia fo MM, how to examine a patient who had died, how to coordinate with other teams (icu) when patients doing poorly etc. in the morning the attending and team would round on the new admits where I would present the new patients, and thenbe dismissed for my post call day.


I did a lot of procedures as a student: lumbar puncture, paracentesis, I&D, even one bone marrow biopsy! on my medicine rotation. Sadly on surgery the students job was to place to foley (i guess an important task, but really?) and to help close. I dont know what students do here, but (outside of the ICU) we rarely got to do LP or paracentisis on our IM patients as residents (attendings themselves not certified, so couldnt teach, procedure would go to consultant who may or may not let you learn)- let alone giving the student a chance

Thinking of other things... on psych and peds i learned how to write a consult and dictate a consult... on ob i caught maybe 5 babies ( not my thing, i know others who did rural ob rotations as a student and caught closer to 50).

Overall, i think I did more as a student compared to students I see here. I learned a lot and as a result was stronger clinically - it showed during my residency. While even with all that I considered myself only average compared to my medical school peers and my FM peers, i have been told here in the US that I was one of the strongest interns and later on resident they had in years - not strongest in book knowledge, but in clinical and practical knowledge. (All of this is a reflection of only my experience- as there are great/poor students and great/poor learning settings in both US/canada)
 
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During my medicine clerkship we were treated like an intern on the team. We had our own (upto 2 patients) that we wrote notes on, reviewed and presented to attending with the teams senior as backup. We participted in rounds, education etc - this is similar to ms3s here

What was different:
. There were 5 medicine teams, everynight each team had an intern oncall 1 senior wouldbe on call for all of medicine (so 5 interns, 1 senior). On call you took care of your team, attended codes, and did a lot of admissions. The medical students were part of the rotation, but were only scheduled on nights their teams senior was on call (so max 1 student overnight). So i took overnight call, roughly every 5 nights where I took first call for my team. Orders were still paperbased - i could write orders and get them cosigned by my resident.

so I learned how to write complete admission orders, i learned how to write for a sliding scale, treat DKA, workup new anemia fo MM, how to examine a patient who had died, how to coordinate with other teams (icu) when patients doing poorly etc. in the morning the attending and team would round on the new admits where I would present the new patients, and thenbe dismissed for my post call day.


I did a lot of procedures as a student: lumbar puncture, paracentesis, I&D, even one bone marrow biopsy! on my medicine rotation. Sadly on surgery the students job was to place to foley (i guess an important task, but really?) and to help close. I dont know what students do here, but (outside of the ICU) we rarely got to do LP or paracentisis on our IM patients as residents (attendings themselves not certified, so couldnt teach, procedure would go to consultant who may or may not let you learn)- let alone giving the student a chance

Thinking of other things... on psych and peds i learned how to write a consult and dictate a consult... on ob i caught maybe 5 babies ( not my thing, i know others who did rural ob rotations as a student and caught closer to 50).

Overall, i think I did more as a student compared to students I see here. I learned a lot and as a result was stronger clinically - it showed during my residency. While even with all that I considered myself only average compared to my medical school peers and my FM peers, i have been told here in the US that I was one of the strongest interns and later on resident they had in years - not strongest in book knowledge, but in clinical and practical knowledge. (All of this is a reflection of only my experience- as there are great/poor students and great/poor learning settings in both US/canada)
Thanks for sharing, interesting to know.
Procedural training is very diluted now for residents, let alone students. Even subIs for 4th year uncommonly provide enough experience for writing orders etc. And you'll find lot of the docs on here think that's great (lol) and that you should essentially postpone everything to intern year to make the curve even more steep.

I would think the US system allows you to learn more zebras, given the usmle content etc.
 

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Thanks for sharing, interesting to know.
Procedural training is very diluted now for residents, let alone students. Even subIs for 4th year uncommonly provide enough experience for writing orders etc. And you'll find lot of the docs on here think that's great (lol) and that you should essentially postpone everything to intern year to make the curve even more steep.

I would think the US system allows you to learn more zebras, given the usmle content etc.
If that's what you think we were arguing for, your comprehension is severely lacking.

When I was a 3rd year we did routinely write orders and see patients independently. If that's largely no longer the case, that seems a detriment to medical education.
 
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Just fyi i was an ms3 in 2011, so its not THAT long ago. Writing paper orders for patients you take care of was a great way to learn. But, I think the biggest change occured when CPOE rolled out and students werent given access to enter orders with a mechanism of resident co-signature. Good for safety, not great for learning.

As a senior resident, i would try to teach my students this skill using old/downtime order sheets to practice writing admit orders for patients they did the h&p on. It really helped solidify knowledge about drug doses, and development of a comrehensive plan without depending on an order set. Many of them were lost without an order set to follow. We would compare their paper orders to my computer ones afterward - great teaching tool in my opinion (so you forgot to order fluids, what would you choose and why?) and kept the student busy when i had other work to do! And the paper would be securely shredded afterward.

I guess to bring it back to the topic: decreasing the length of medical school or residency without increasing the number or educational/clinically relevant/practical-hands on type of experiences makes a recipie for disaster. Could it be done? Sure, but requires perhaps a complete change in the approach and system of learning. its not enough to just cut out rotations! Cut out the esoteric!

most important: the right type of learner who will take responsibility to seek out opportunities - read/see/do. Many need the extra time to build skills that will carry them for their career. The less they see and do as a trainee, the weaker they will be as an attending.
 
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If that's what you think we were arguing for, your comprehension is severely lacking.

When I was a 3rd year we did routinely write orders and see patients independently. If that's largely no longer the case, that seems a detriment to medical education.
Seeing patients independently is the general norm in 3rd year for anything inpatient and adult outpatient. I know for peds & ob outpatient there's a lot of variance.

I had 2 rotations with paper scripts and wrote orders down for every one of the 15-40 patients I saw per day and it was the best learning experience. On EMRs, students aren't placing orders except for 4th year subIs and those are increasing limited now. A lot of subIs are more or less the same as 3rd year rotations nowadays too.
 
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Seeing patients independently is the general norm in 3rd year for anything inpatient and adult outpatient. I know for peds & ob outpatient there's a lot of variance.

I had 2 rotations with paper scripts and wrote orders down for every one of the 15-40 patients I saw per day and it was the best learning experience. On EMRs, students aren't placing orders except for 4th year subIs and those are increasing limited now. A lot of subIs are more or less the same as 3rd year rotations nowadays too.
That's how it should be. General peds you should be able to do alone, sub-specialty I can see not. OB is tricky so as long as its not pure shadowing, I'm not going to complain.

I don't love that with EMRs note writing/orders are curtailed. The latter bothers me less as with EMR it takes all of 10 minutes to pick up how to do it.

Notes are a whole different ballgame.
 
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