Social Policy in Ontario

Can new approaches to medical curriculum solve the family doctor shortage?

Posted on March 22, 2024 in Health Delivery System

Source: UniversityAffairs.ca — Authors: Hannah Liddle

UniversityAffairs.ca – Features
Mar 20 2024.   By Hannah Liddle

Three new medical schools and an innovative family medicine program look to alleviate a crisis in primary care.

With six million Canadians currently lacking any affiliation to a family doctor, it’s likely that you or someone you know has firsthand experience reconciling the need for primary care with what many describe as a broken system. For emergency physicians working in our hospitals and clinics, the consequences of the family doctor shortage can take the form of nightmarish scenarios. Tony Sanfilippo, an academic physician, clinical cardiologist and professor at Queen’s University, says he sees the shortage everywhere: from patients who aren’t getting preventative care to stem the development of cancer, to newborns being discharged from the hospital with no family doctor. “These babies won’t have somewhere to go for immunizations or for checkups,” he said. “This is having a huge impact on individuals, but it’s also having an impact on the system.”

Many patients – or those who are still willing to go – travel to overcrowded and overburdened emergency rooms where they are eventually seen by an emergency room physician such as Teresa Chan. Dr. Chan is the founding dean of the Toronto Metropolitan University (TMU) school of medicine and a practicing emergency physician with Hamilton Health Sciences. She says those coming through the doors can’t be blamed for going to the emergency room for help, but help isn’t always available because of a shortage of trained professionals, staffed beds, and a lack of integration between hospitals and primary care physicians. “People come in at four or five after work, and then wait six to eight hours to see me, and I can’t do anything about their back pain,” she said. “I get the sense of despair they’re experiencing, because they’re coming to us as a solution shop – and we don’t always have the solution.”

“The number of family physicians will not come close to addressing the needs of Canadians.”

The post-pandemic Canadian health care system is its “sickest patient,” says Dr. Chan. Still, she believes the systems in place fueling the family physician shortage can change – and is working to help medical schools evolve to become part of the solution. “Our job is to try to see what we can do to transform the system, and medical education, healthcare research, and innovation are the ways to do that,” she says. “That’s what medical schools do.”

Canada currently has 17 medical schools with three more opening within the next three years at TMU, Simon Fraser University and the University of Prince Edward Island. University Affairs spoke to academic leaders from these schools and an innovative family medicine stream at Queen’s University to learn how they’re taking the novel opportunity to rethink and redesign curriculum for family physicians in Canada from the moment they welcome students.

The big picture: problems in the pipeline 

Canada’s medical schools currently graduate just under 3,000 new doctors each year, but family physicians are the slowest growing category. According to data from the Canadian Resident Matching Service (CaRMS), less than 50 per cent of students in medical school will choose family medicine as a career, with less than half of those students opting to provide comprehensive care in clinical settings. That amounts to approximately 700 new family physicians graduating each year.

To make problems worse, nearly 20 per cent of the 47,000 family doctors in Canada are planning to retire in the next five years and, on average, every family physician in Canada has approximately 1,500 patients. To accommodate the Canadians currently unattached to a family doctor, not accounting for those whose doctors might soon retire, the medical school system will need to graduate about 4,000 new family doctors each year. Despite provincial funding efforts to increase the number of available medical training positions (known as “seats”), the number of family physicians “will not come close” to addressing the needs of Canadians, says Dr. Sanfilippo, even when the new schools begin graduating physicians.

A major factor contributing to the problem, in Dr. Sanfilippo’s view, is an overly restrictive admissions process and a training environment that has students spending up to four years being exposed to over 30 different specialties, ranging from anesthesiology and gerontology to neurology, gynecology and plastic surgery. This takes away valuable time from students who’ve committed to family medicine and could be practicing in clinical settings. “Medical schools should have some consideration of the needs of society when admitting and training students for medicine, and the curriculum we should develop should be specifically aligned to ultimate career goals,” he said. “It’s no longer reasonable to spend four years of medical school exploring career options.”

Another worrying contributor to the shortage is the fact that residency spots for family physicians are not being filled by graduating students. In 2023, there were 110 vacant residency spots across Canada, 100 of which were in family medicine – the highest number in a decade. The College of Family Physicians of Canada (CFPC) says that the reasons for this are unclear but acknowledges that “interest in the specialty hasn’t kept pace with the growth in residency positions.”

Anchaleena Mandal, co-chair of the Society of Rural Physicians of Canada Resident Committee, suggests fading interest among students could be caused by fear of burnout in a profession that has increasingly high levels of administrative burden; a perception among students that the profession is not “elite” in part driven by negative media coverage; students not wanting to move to remote or rural communities or having misgivings about location; and the allure of specialties that provide higher compensation.

None of those reasons have dissuaded Dr. Mandal, who is a first-year resident in the Queen’s family medicine program. Growing up in Iqaluit, where her family immigrated from India, she’s seen what a fragmented, ill-resourced health care system looks like – and the incredible impact family doctors have on patients within them. “There was a small team of local family doctors and visiting locums [doctors], who really were my role models,” she says.

Dedicated family medicine programs

In response to the severity of the family doctor shortage, two universities have initiated dedicated programs that only admit students who have expressed a primary interest in family medicine. Queen’s launched the first program of this kind in Fall 2023 with financial support from the Ontario government. The six-year program has 20 seats and is entirely focused on family medicine training. Based out of Queen’s satellite campus at Lakeridge Health’s Oshawa hospital, the program is integrating students into Durham-region clinics and health centres where an estimated 44,000 people are without a primary care doctor.

The program is similar in design to one implemented at the Northern Ontario School of Medicine (NOSM), which is focused on bringing students into the community as early as their first year of training. This technique, pioneered by NOSM’s founding dean emeritus Roger Strasser, has proven highly successful: in 2023, 88 per cent of studentswho completed undergraduate and postgraduate training at NOSM have stayed to practice in northern Ontario. While comparable, the Queen’s-Lakeridge program will have no secondary admissions process whereby students apply for a specific specialty after completing their studies: after six years, students emerge fully qualified to become family physicians. “This is an example of a more specialized and targeted medical education that society now needs,” acknowledges Dr. Sanfilippo.

It is also one that Simon Fraser University intends to model. British Columbia currently has only one medical school and one of the highest rates of residents without a family physician. In November 2022, British Columbia Premier David Eby announced millions of dollars in funding for the new medical school at SFU’s Surrey campus and the school hired Dr. Strasser as interim dean to provide strategic leadership in planning and implementation. The school’s curriculum will focus on primary and community care and will graduate students ready to serve the Fraser Health region, a large geographic area comprising urban, semi-urban and rural communities stretching from the Fraser Canyon to the Vancouver suburbs of Burnaby and Delta. In September 2023, B.C.’s minister of postsecondary education announced the school would offer a dedicated program for family and primary medicine and nodded to the Queen’s program as giving the province “a sense of what was possible.”

But the new acting dean at SFU, David Price, says that the school is far from a NOSM of the West. “This will be a B.C.-designed and B.C.-centric school. We are starting in Surrey, which is one of the fastest growing urban areas in Canada,” said Dr. Price. “Our goal is to focus on primary and community care, but we are not exclusively focusing on family medicine: community includes psychiatry, pediatrics, general internal medicine, etc. We are trying to graduate students ready to practice in the Fraser Health environment, and as time goes on and the school expands, exposing and making sure our residents are comfortable working in more rural and isolated areas as well.”

Community placements are a critical part of family doctor retention, says Dr. Mandal. “There’s literature showing that physicians who are integrated into the workplace and community, and who develop a sense of belonging, are more likely to stay in that community.” Early community contact will allow students opportunities for feedback and appreciation from local patients, and the chance to build collegiality with other health providers, she says, which will encourage them to stay in the long run.

Health systems science

TMU’s school of medicine will open in 2025 and will be taking a new-to-Canada approach to clinical placements for all medical students called “longitudinal integrated clerkships,” or LICs. LICs are clinical rotations that are longer than the typical two-week stints that students complete when exploring various specialties and will allow students to see patients more than once, and therefore have a better sense of patient outcomes. “This is really important if we are going to have people who understand the continuum of care,” says Dr. Chan. “These rotations will allow them to experience what’s going on with the system so they can see it with fresh eyes.”

A second element to the program structure will include a series of courses in health systems science, which teaches students how to work in Canada’s often complicated health care network – and how to care and advocate for patients who move through it. The courses will have less lecture time and more group inquiry-based learning, with students repeating concepts and analogies of patient care to prepare for clinical settings. While the courses are akin to those at other schools, Dr. Chan says TMU will integrate emerging technologies into case studies. “It could include how diabetes might evolve with patch glucometers, or it might include a case where someone is sent home in a hospital-to-home program, where they have monitors,” she said. “We want to prepare students for that future reality.” By combining LICs with health systems science, students will “understand what life is like for the patients, which is really powerful,” adds Dr. Chan.

Community-centric primary care

Both SFU and TMU are placing curricular emphasis on community-centric primary care, which covers a broad range of primary prevention that includes public health and primary services delivered by interdisciplinary health professionals. This approach to medical practice takes on the responsibility for the health of a specific population where both the individual and community are the focus of care and treatment. “Schools teach how to be patient-centered, but when you bring all the patients together and start listening and do […] a qualitative analysis of multiple people’s journeys, I think you start to see where solutions are at the systems level,” explains Dr. Chan. “Community-centered primary care means zooming out to see the bigger picture.”

Another key element to community-centric primary care is its attention to the social determinants of health. These factors often include income, education, employment, housing, and gender and extend to experiences of discrimination, racism and historical trauma – important health determinants for equity-seeking groups in Canada.

“We’re trying to create a curriculum to graduate students ready to practice in 2030, 2035 and beyond… students who know how to use the tools of the digital world and to really direct that towards patient care.”

Providing culturally appropriate and high-quality care to the 32 First Nations and six Métis communities in the Fraser Health region has been top priority at SFU’s medical school from the beginning. In early 2022, SFU held an engagement session with Indigenous students, faculty and staff to ask how the new medical program could “do things differently” to meet the needs of Indigenous peoples across the province. Since then, the school has appointed deputy chief medical officer of the BC First Nations Health Authority and well-respected First Nations leader Evan Adams as its associate dean of Indigenous health. Dr. Adams is tasked with Indigenizing the medical school: embedding and equalizing Indigenous ways of knowing into the school’s foundations of learning. Dr Price hopes the appointment sends a “very strong message” that Indigenous health care is a key pillar on which the school is built. “Every aspect of our curriculum, our clinical placements, takes into account Indigenous ways of knowing and really focuses on Indigenous health care,” says Dr. Price. “It’s baked right into the DNA of the school.”

Team-based care

Community-centered care is often aligned with team-based primary care, where family physicians work interdependently with a team of health professionals such as nurse practitioners, nurses, physician assistants, pharmacists, social workers and medical students to provide primary care. Team-based care can reduce wait times for patients, increase access to care and provide better delivery of patient-centered care, according to Christine Newton, past president of CFPC. At its best, team-based care reduces the burden on family doctors who wouldn’t have to provide additional services to each patient while helping them navigate a complex and disjointed health system. Team-based or multidisciplinary care is relatively newer to the medical field, but it’s an approach that the Canadian Medical Association (CMA) wants provinces to adopt, and soon. Last year, CMA called on provincial governments to establish primary care teams for 50 per cent of Canadians in five years, and 80 per cent within 10.

Prince Edward Island is a leader in the development of team-based care, according to Paul Young, the chief operating officer for UPEI’s new faculty of medicine, set to open in 2025. The new school will offer a joint doctor of medicine program that will be primarily based on Memorial University of Newfoundland’s established curriculum, modified based on the needs of Prince Edward Islanders – with team-based care being a core element.

In March 2023, Deputy Prime Minister and Minister of Finance Chrystia Freeland joined the Premier of P.E.I, Denis King, and the interim president and vice-chancellor of UPEI, Greg Keefe, in announcing $48.8 million in joint funding for a medical education building that would house the new faculty at UPEI and provide a new learning environment for medical and interprofessional health education students such as future nurses, nurse practitioners and paramedics. It will also house an expanded UPEI health and wellness centre which will eventually transition to a patient “medical home” and psychology clinic that will service 10,000 patients per year. The medical home is intended to be a model for primary care delivery that will rely on team-based care to reduce wait times for family doctors and relieve pressure on Island walk-in clinics, emergency rooms, outpatient departments and physicians, according to a statement from the university. Mr. Young says it is “not alone a silver bullet,” but that he hopes other provinces can look at how P.E.I can “test-drive these models and reflect on and evaluate the impact they have on the system, to be measured across the country.”

One of TMU’s core curriculum pillars is to equip students with the skills to develop the interprofessional health networks that team-based care relies on. Dr. Chan says that to build these networks students need to be working with other professions from the outset to “gain insights together and create opportunities to learn.” TMU’s medical school is looking to potentially partner with its Chang School of Continuing Education and to bring people together across multiple faculties, such as engineering and computer science, to understand how future health teams can be developed.

“We need to ensure that high school students know that being in family medicine is an extraordinarily rewarding and fulfilling career.”

Learning in medical technology and innovation will also be essential to future physicians’ ability to diagnose system problems in health care, says Dr. Chan. Understanding data and analytics, for example, could be a game-changer for how interprofessional teams communicate about a patient’s journey through the system. “It might be a simple thing, like having a common booking system – but it can be more complex than that,” she says about the technology. “If you have three healthcare practitioners who see a person on the same day, outcomes are better, but [a physician] might not be able to see that, because we don’t have the data.” If data is shared and understood by future family physicians and their teams almost in real time, they can quickly figure out what is working and what isn’t and build teams that are more effective and efficient in those conditions. “That is probably where the biggest margins are,” says Dr. Chan, “because another roster drug for cardiology would have marginal gains compared to a better organized system.”

Dr. Price says SFU’s curriculum will also focus on digital health and understanding how to use artificial intelligence in the health care landscape. “We’re trying to create a curriculum to graduate students ready to practice in 2030, 2035 and beyond… students who know how to use the tools of the digital world and to really direct that towards patient care,” he says.

A collective responsibility

While the new medical programs hold a lot of promise for alleviating the family doctor shortage, experts acknowledge that solving it entirely is a collective responsibility that extends to and beyond all medical schools in Canada.

Many in the medical community point to the role of provincial health departments. “Our ministries of health have a responsibility to look at this problem and say, how are we going to deal with it? And who is involved in dealing with it, right?” says Dr. Sanfilippo. “But the ministries can’t fix this alone.”

Promoting a career in medicine as early as high school is an important first step. “We need to ensure that high school students know that being in family medicine is an extraordinarily rewarding and fulfilling career, and we need to emphasize that to our undergraduate university students and expose them to the breadth and depth and wonder of family medicine,” says Dr. Price.

The medical community must also take a more holistic view of applicants, says Dr. Chan, and be more open to those who may be unaware of their potential in family medicine – those from equity-deserving groups, those who’ve left the profession but can still return, and those who are looking to change career paths or careers entirely. “We need to make health care and medicine very welcoming to different people with different ideas, because they’re going to be the secret to our success,” she says. “If we keep repeating what we had before, we’re not going to have the changes we so sorely need. Because an engineer that understands human factors is the person who is going to revolutionize the way we deliver health care – but she doesn’t know she needs to come to healthcare yet.”

After she completes her residency, Dr. Mandal plans to return to Iqaluit to work as a family physician. For her, solving the shortage starts at the grassroots level. “It starts with parents, families and communities playing a role in raising children to succeed academically and pursue postsecondary education, and family physicians to be positive role models for future generations,” she says. “Being in this specialty, we truly make a difference in our community through the work that we do.”

PUBLISHED BY: Hannah Liddle – the digital journalist for University Affairs.

https://universityaffairs.ca/features/feature-article/can-new-approaches-to-medical-curriculum-solve-the-family-doctor-shortage/?utm_source=University+Affairs+e-newsletter&utm_campaign=fbcdab6d4c-EMAIL_CAMPAIGN_2024_03_20&utm_medium=email&utm_term=0_314bc2ee29-fbcdab6d4c-425255637

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