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Why Medical Students Aren’t Choosing Family Medicine

Doctors in Nova Scotia aren’t getting any younger. More than half of all physicians practising in the province are over the age of 50. According to the province’s Physician Resource Plan, Nova Scotia needs to recruit 1,000 physicians over the next 10 years, in order to replace retiring and relocating doctors, and to fill new positions.It’s never been more important to ensure that medical students trained in Nova Scotia are encouraged to put down roots in the province.

But that’s easier said than done – and right now, fewer students than ever before are choosing family medicine as their area of specialty. As with most issues in the health-care system, it’s a complex problem that’s going to require serious changes.

Most medical students are Nova Scotians
Dalhousie Medical School is the main recruitment university for new family doctors in Nova Scotia. It gets about 1,000 applications each year for just over 100 spaces (most successful applicants have applied two or more times). The university considers an applicant’s GPA, MCAT score, and volunteer work, and conducts an extensive interview process.

Where applicants live also matters. There are 108 spots with provincial funding: 63 are held for Nova Scotia applicants, 30 for New Brunswick applicants (who study at Dalhousie Medicine New Brunswick in Saint John, N.B.), six for P.E.I. applicants, and nine for applicants outside of the Maritimes. (See the 2018 class breakdown.)

Declining numbers in family medicine
Medical students pick a specialty in their fourth year. This year, only 14 students from Dalhousie (13%) matched to family medicine residency spots at Dalhousie – and of those, only seven were to spots in Nova Scotia (of 29 possible spots).

In addition, just 20.4% of Dalhousie Medical School students chose to specialize in family medicine overall, down from 29.7% the year before, and well below the national average of 33.2%. It’s worth noting that at Dalhousie Medicine New Brunswick, a higher rate of students picked family medicine, exceeding the national average. By comparison, back in 2014, 41.7% of Dalhousie Medical School graduates matched to family medicine.

Dr. Kathleen Horrey is the undergraduate medical education program director for family medicine at Dalhousie University. “When we saw the difference between our two campuses, we started a discussion with the Faculty of Medicine about changing the delivery of our curriculum so we can meet our obligations to the community that we’re trying to serve.”

She says the medical school recently released a “Family Medicine Project Charter” that aims to boost the profile of family medicine at the university. “The goal will be to have 50% of our medical students choose family medicine by 2022. We’ve got a lot of work to do.”

Early exposure is key
Michael Mackley is a second-year medical student at Dalhousie Medical School and president of the Dalhousie Medical Students’ Society. He says medical students get little exposure to family doctors in their first two years of training. “Almost all of our teaching is done by specialists,” he says. “We don’t meet many family doctors.”

Second-year Dalhousie medical student Kyle Kilby says this is affecting students. “It’s hard to see yourself as a family doctor when you have no role models in the field,” he says.

More family physician leaders needed
Dr. Horrey also thinks family doctors need more visibility on campus. “Students need to see the scope of practice family physicians have, which will reduce the impact of hidden curriculum – the informal learning that students witness.”

As medical students rotate through the specialties during their training, they interact with physicians who may not always convey positive messages about family medicine. “Some students feel ashamed to admit that they’re thinking of pursuing family medicine,” says Dr. Horrey.

Seeing more family doctors as teachers and leaders in the medical community would help. “If medical students don’t see us in the role of expert, what does that say about our position in the health-care system?” asks Dr. Horrey. “We need to weed out those negative biases and find a way to support community family physicians to teach.”

More flexibility for family doctors
That will require a significant change in how physicians are paid. Most family doctors are paid with a fee-for-service model, so they’re not paid when they take time away from their busy practices to teach medical students. It’s often more convenient for a specialist already working at the university, who gets paid to teach, to do the job. Having a flexible blended payment model for family physicians would make that easier – and allow them to contribute in an important way.

During the first two years of medical school, students learn general skills that apply across medical specialities. “Family physicians could be teaching us clinical skills,” says Kilby, including how to take a patient’s history and how to perform general physical exams. “That would suit family physicians perfectly; they’re the ones who do them every day.”

More hands-on experiences
Dr. Horrey hopes the revamped medical curriculum at Dalhousie also includes a mandatory placement with a family physician for all first-year students. “A half-day each week for six weeks,” she says. “Students would spend time with a family physician in the community. We’d need to recruit more preceptors in Halifax and Dartmouth.” She’d also like to see more support across the province for family doctors to provide clerkships and electives to students.

Stressful work environment
But with ongoing physician shortages in Nova Scotia, the work environment for family doctors isn’t helping the situation. “We meet specialists and they talk about their work/life balance,” says Mackley. “The few family doctors we do meet seem overworked. It’s not particularly appealing to students.”

Kilby saw that during his Rural Week training at the end of his first year. “I was paired with a family physician in the northern zone,” he says. “I had a wonderful experience but it was obvious that the system isn’t working as it should – having two doctors responsible for an entire community, including an emergency room. We talked a lot about rural medicine and what we need to make it work, and it’s more than two people.”

The experience hasn’t turned him off of family medicine, but it has made him wonder what would await him if he pursues it in Nova Scotia.

Building rural connections
Just because a medical student is from a rural community doesn’t guarantee they’ll want to work there. “You get used to working in a big tertiary centre where you have more resources and support,” says Mackley. “It can seem challenging to hop back out to the rural community.”

Giving all medical students the chance to build confidence with more hands-on experience in rural communities may be a better approach. That could include more opportunities for taking part in what’s called a Longitudinal Integrated Clerkship (LIC). That’s where third-year medical students spend the year working with a family doctor in a rural community, getting to see how rural medicine works. “They see that rural medicine isn’t as scary as they thought it might be,” says Dr. Horrey. Next year, Dalhousie will offer four LIC placements in Cape Breton.

A gradual process
Ultimately, boosting the number of medical graduates going into family medicine will take time. “There’s not a simple switch to correct the problem,” Dr. Horrey says. “It’s about making targeted changes that will better support family physicians in teaching medical students and address the needs of our communities.”

In an upcoming blog post, we’ll dive deeper into exploring the early experiences of residents and new-to-practice physicians in Nova Scotia.

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