You learn a lot in residency, but not everything: Early-career FPs highlights knowledge gaps

Early-career family physicians in Canada don’t feel fully prepared for practice in numerous key areas a recent qualitative coast-to-coast study discovered.

The study, published in BMC Medical Education, surveyed 75 FPs who’d completed their residency in Canada, with 59 taking part in the focus groups. The study looked at the 37 core activities in the Residency Training Profile identified by the College of Family Physicians of Canada (CFPC).

But the news was not all bad. Early-career FPs reported being well-prepared to provide continuous and coordinated care for patients with common presentations and to deliver various services to different populations. They were well-prepared to manage EMRs, participate in team-based care, provide regular and after-hours coverage, and assume leadership and teaching roles.

Meanwhile, Canadian early-career family physicians reported being less prepared for virtual care, business management, providing culturally safe care, delivering specific services in emergency care hospitals, obstetrics, self-care, engaging with the local communities, and conducting research activities, said principal investigator and lead author Monica Aggarwal.

In addition, FPs indicated they felt unprepared for managing difficult patients, having multiple responsibilities, addressing multiple concerns of patients and dealing with failure.

“I remember a participant saying they felt the training program was a ‘bubble,’ as it exposed trainees to the positive aspects of family medicine but omitted the profession’s challenging or more complex experiences,” said Aggarwal, assistant professor at the Dalla Lana School of Public Health at the University of Toronto, in an interview with the Medical Post. “I was surprised to hear graduates say they did not get sufficient exposure to difficult situations such as handling difficult patients, working with complex populations, and conducting procedures in high-stress situations. As such, they struggled with managing these issues in their practice.”

Aggarwal, whose primary research focus is health services delivery and health policy in Canada, especially related to primary healthcare, also said she was concerned that family physicians may not get adequate exposure to business management. “I feel that addressing these concerns is critical for ensuring the well-being and resilience of our FPs, especially with the challenges the profession is currently facing in Canada,” she said.

Need for improvement
The goal of the study, said Aggarwal, was to identify areas where family physicians of the future could be better supported, given the current declines in the delivery of full-service comprehensive care.

“Numerous factors impact the practice decisions of family physicians, one of which is medical education,” said Aggarwal. “This study aimed to examine whether FPs felt prepared for independent practice after completing family medicine residency training and to identify areas for improvement to better support family physicians in the future.”

Dr. Stephanie Zhou, an FP and addictions physician in Toronto who has been in practice for three years, told the Medical Post that she witnesses her peers having difficulty in certain areas, especially, “business management and billing, negotiating contracts and how to evaluate locum opportunities. Also (challenging) are the medico-legal aspects of practice, how to communicate with patients when the interaction is unsatisfactory to patient expectations.” 

Dr. Zhou, who is alsoassistant professor at U of T’s Temerty Faculty of Medicine, where she teaches the financial literacy curriculum, pointed out that since the participants were interviewed between September 2020 and May 2021, some of the results are not surprising. “They were interviewed at a time when virtual care . . .  was new to many. This was also a time when some were redeployed or changed to have a virtual component that made it hard for new grads in those years to pick up physical examination skills, for example, obstetrics and ER.”

Dr. Lawrence Loh, executive director and CEO of the CFPC, said the study reinforces the need for improved support for physicians transitioning into family practice.

“The increasing complexity of family practice, both on the practice management as well as the clinical side, is why we are pursuing changes in both the training and practice environment,” he said, referencing the college’s pursuit of the introduction of a three-year integrated residency program.

“Many of the things that people are feeling a bit less prepared for are also areas of practice that have emerged in recent times. So virtual care, for example, culturally safe care . . . they need to be covered because we know that it's going to be an important part of how we practice going forward.” He also noted that, since the last residency reform, there has also been a greater emphasis on mental health and substance use, Indigenous health, palliative care, digital health, end-of-life care and MAiD.

Dr. Loh said he believes residency programs are doing a good job of putting together an excellent curriculum for new graduates and early-career physicians. “But we need to actually strengthen and improve, not necessarily the practice and clinical components, but really that support for transition to practice and also that support for working in today's practice environment. So we’re trying to work in, for example, team-based care, and ways to address things like administrative burden.”

Comments from study participants
The study showed early-career FPs were least ready to provide virtual care, with one quoted in the study saying, “I wasn’t prepared for this, I get a lot of people who might seek opioids, benzos, and they’re asking for prescriptions of those all over the phone. And you can’t really see them. You can’t assess them. . ..”

The lack of preparedness for business management and administration emerged as a prominent theme in the focus groups. One participant said, “I just found that residency did not at all to prepare me for starting my own practice of my own. Like, no part of it. Like, from the billing to . . . like any of it, really. Because what I was exposed to in residency, even though I trained where I set up my practice, it’s still like, you know, as a resident, you’re often sheltered from that aspect, right.” 

Other participants talked about their lack of preparedness for dealing with time-consuming administrative processes such as insurance forms: “Insurance forms or disability paperwork for a patient. I really wish that even if there was one god-awful lecture on it where I could have taken some tips forward or something would have stuck in my brain, maybe there would have been something that better prepared for the vast majority of things that we get asked to fill out on a daily basis,” said another participant.

The study recommended that, as part of the introduction of the three-year program by the CFPC, trainees be provided with more exposure to learning in specific areas and settings. It said introducing a new curriculum “may facilitate the production of an FP workforce better prepared for practice. However, this must be accompanied by supporting FM programs, preceptors and mentorship programs.”

To that, Aggarwal added: “Trainees should be paired with educators/preceptors who will provide longitudinal exposure to patients from various populations and work settings to help develop their knowledge, skills, competencies and capabilities. In addition, there should be formalized mentorship program that matches residents with mentors during and after the completion of the program to facilitate the transition to practice. These changes would require sufficient support for the family medicine programs, faculty, and mentors.”

Dr. Zhou strongly supports the study’s recommendations on a formalized mentorship program.

“I would take that further to have certain objectives the mentor should guide the mentee on. Sometimes the mentee doesn't know what they need help with until they experience it themselves and often in that case it might be too late—or example, when the mentee starts a new locum and finds that they can't handle a practice with 1,500 patients and 150 plus messages in the inbox, or the mentee receives a patient complaint. Instead of having an open-ended mentorship, there should be certain topics the mentor discusses to 'immunize' the mentee for what's to come.”

Advice for young FPs
Asked if her work studying early career physicians has led to any advice for them, Aggarwal said, “Plan what you want to do at the end of training and align with preceptors with similar interests who will help you obtain the exposure you need to be prepared for practice. Look for mentors who can provide guidance and support throughout your career journey—not only during your training, but also as you transition into independent practice. If you want a full-service comprehensive practice, work in rural settings and put yourself in uncomfortable situations.”

Lastly, Aggarwal said self-care is important to avoid burnout. “Make time for activities that rejuvenate you, engage in hobbies, maintain a healthy work-life balance, spend time with your family and friends, and seek support when needed—resilience is a skill to succeed in family medicine that can be developed and nurtured over time.”