Roger Collier | CMAJ | January 10, 2017
Many medical students hear disparaging comments about family medicine from professors and clinicians during their training.
Family physicians have undemanding, boring careers. They are of a lower status than other doctors. Much of what happens in the office of a general practitioner (GP) isn’t even proper medicine. If medical students don’t work hard, they may “end up just as a GP.”
These are some of the comments medical students in the United Kingdom reported hearing from clinicians, educators and academics in a recent survey. Of the 3680 students surveyed, 76% had heard negative comments about family medicine at medical school or during clinical training. Most students, 91%, also believed their peers held negative attitudes about general practice.
While reading an article about the UK survey, Dr. Kevin Dueck, a family medicine resident at McMaster University, found similarities with the experiences of Canadian medical students. “It is prevalent here, can’t say the article surprised me at all,” he said. “Family medicine was the best fit for me based on my interests and priorities, but I can see the comments shifting trainees’ directions. The comments also lead to a culture that devalues primary care and is passed on from staff to trainee.”
This is indeed the concern of the Royal College of General Practitioners in the UK, which described the survey’s findings in a report called Destination GP, released in partnership with the Medical Schools Council. According to the report, the demand for primary care services in the National Health Service (NHS) has increased 16% over the past seven years, but the number of new GPs has not kept pace. “It is widely accepted that for the NHS to meet the growing and increasingly complex needs of patients, we must recruit more GPs,” the report concludes. “Improving the experiences and perceptions of medical students to make general practice a career destination of choice is a key part of this.”
In Canada, the percentage of medical students choosing family medicine as their career hit an all-time low of 23% in the 1990s. This was attributed in part to government reductions in residency positions, but also linked to “a general impression that family medicine was a lower-class career option,” the College of Family Physicians of Canada said in a statement. “It’s fair to say that, to a lesser degree, this reputation continues to exist in Canada.”
Through a series of initiatives — engaging students with Family Medicine Interest Groups, improving remuneration models for general practice, having family medicine recognized as a specialty — the college was able to help improve the rate of students entering the field to 38.5% by 2015.
In 2017, however, the number of medical students who made family medicine their first choice of specialty dropped to 983, down from 1050 the previous year. “We hope that is just a one-year blip and not the start of a new trend in Canada,” the Canadian Federation of Medical Students said in a statement. The federation also noted that there is no “concrete evidence” pointing to any particular reason that medical students don’t enter family medicine. There is evidence, however, that the “most common and desired” residency transfer is from another specialty into family medicine and “not the other way around.”
Still, there appears to be a general perception in medical schools that “smart” students should pursue specialties other than family medicine, said Kirsten Kukula, a medical student at Dalhousie University and the student representative for the College of Family Physicians of Canada. “We call this the hidden curriculum, where becoming a family physician is considered ‘settling’,” she said.
Kukula has received a range of negative responses when people learned she had chosen family medicine. “You want to be a family doctor?” she recalled one person saying. “You must be really sick of studying.”
To combat the problem in Nova Scotia, various provincial health organizations have partnered to promote positive family medicine learning opportunities for students, including visits to rural practices to speak with local doctors. “My sense and my hope is that initiatives such as these are presenting family medicine as being a challenging, versatile, and rewarding career,” said Kukula.
Although some students may hear disparaging comments about “settling” for family medicine, views on general practice are far from uniform in Canadian medical schools, according to Dr. Chris Beavington, a family medicine resident at the University of Alberta and a board member of Resident Doctors of Canada. Students are also likely to hear negative comments about other specialties during their training, he noted.
“It is unfortunate that these gaps in collegiality exist,” said Beavington. “I believe that the medical community needs to recognize the role of all clinicians and allied health providers if it is to surmount the obstacles of a fragmented profession.”
Problems with lack of collegiality between specialties can affect not only medical students, but also patients, according to Dr. Jon Hislop, a family physician in British Columbia. Although he has many excellent interactions with specialists, he does feel that some occasionally hold GPs to unrealistic standards and, even worse, question their competence in front of patients.