Vocational training of residents preparing to practice family medicine

Walter Rosser, Lawrence Leung

HK Pract 2009;31:1-3

Across the world, there are remarkable differences in the duration, preparation and the style of programmes for a vocational trainee entering family medicine. In Canada, the duration of the training programme is only 2 years after graduation from medical school; in the US and the UK 3 years, in some European countries 4 to 5 years and in Hong Kong, 6 years. What could possibly justify such a huge variation presumably for a similar product in different parts of the world?

The Canadians would argue that the country needs about 50% of practitioners engaged in family medicine to provide primary care to all of the population.Maintaining this ratio is ever a struggle as family medicine has always been a less attractive option to medical graduates than some other specialties.However, the Canadian programmes are very organized to integrate training in family medicine with gaining skills in other specialty areas.¹ As an example, many programmes now have the resident spending 3 or 4 half-days per week in a family practice clinic and integrating relevant skills in surgery, medicine, paediatrics or psychiatry as well as obstetrics and ENT, dermatology etc.^2,3 Here in Canada, the short duration of family medicine training is influenced by politics as the government is fully responsible for providing health care to all of the population and does not believe it could better the system with a longer training programme.Having said that, about 40% of family medicine residents take an extra third year of training (the PGY3 option) to specialise in emergency medicine, palliative care, anaesthesia, rural health and some 8 other areas.

At the end of their two years of training, all residents write a certification examination from the College of Family Physicians of Canada (CFPC) which is required for an independent practising licence in all Canadian provinces.This family medicine residency programme is administered by all 17 Canadian medical schools and is subject to careful scrutiny by an independent accreditation committee once every 5 years.¹ This accreditation is carried out by CFPC and definitely has "teeth" as almost half of all family medicine residency programmes in Canada in the past 5 years were put on probation when they fell short of the recognised standards.This leads to the discussion amongst academic family physicians whether the duration of our residency programme is too short for the required knowledge and skills.On the other hand, others would argue that the clinical clerk-ship in the undergraduate medical programme already does a good job of preparing students for a generalist practice and hence 2 years of residency is indeed sufficient.

In United States, family practice training is a 3 year programme leading to the certification from the American Board of Family Practice.⁴ Half the programmes in the US are run by Universities and the other half by community based hospitals with or without University connections.There will be at least 2 years of hospital based experience with some integration in family practice clinics and then spending 4-6 months or even 1 year in a designated family practice.However, there is a much lower demand for family physicians in the US with approximately 12% of medical school graduates taking up family medicine training.Indeed, there is wide variation in experience and exposure with some programmes emphasizing procedures while others may emphasize research, clinical abilities or counselling skills.

The National Health Service (NHS) in UK not only provides one of the best standing testimony of cost-effective health care since World War II, it also blueprints a system of vocational training in primary care which has been widely adopted around the world including Australia, New Zealand, South Africa and to a lesser extent, Hong Kong.⁵ In UK, vocational training programmes are run by the Royal College of General Practitioners (RCGP) and function quite separately from the Universities.GP trainers do not hold University appointments, as they would normally do in Canada.However, like Canada, vocational programme standards are reviewed and maintained by RCGP.Most vocational programmes last for 3 years: two years of hospital based training in blocks of 3-6 months for selected disciplines and then one year in a training practice to acquire the principles of general practice. This will conclude with a comprehensive assessment of both knowledge and skills hosted by the National Office of Summative Assessment (NOSA), leading to a Certificate of Completion of Training (CCT). With this certificate, the trainee can start independent practice and work towards a principal in future. As a further benchmark of excellence in general practice, all vocational trainees are encouraged to take the Membership examination of RCGP (MRCGP), though not mandatory for practice licensure.UK has approximately half of its physicians in general practice and is also having difficulty is maintaining the ratio.

European counties have a variety of vocational training programmes of varying duration.In Nijmegan, Holland, a combined family medicine residency has been developed incorporating a PhD programme that requires 5 or 6 years. This results in a trained clinician, who will also earn a PhD from clinical research. This programme not only fosters research in the discipline of family medicine, it also trains sufficient number of academic family physicians as new blood for education and research and maintain the 50/50 ratio of specialists with practising family physicians.⁶

In Hong Kong, family medicine vocational training is offered to medical school graduates as a structured 6 years training.This is administered by the Hong Kong Academy of Medicine through its member college, the Hong Kong College of Family Physicians (HKCFP).The initial Basic Training takes 4 years where the trainees spend equal amount of time in hospital and community setting as they gain solid grounding on their knowledge and management skills as family physicians.This period will conclude with the trainees sitting the Conjoint FRACGP/FHKCFP Fellowship examination.After that is a period of 2 years of Higher Training where trainees will practise independently in the community with a regular supervisor from the pool of assigned clinical supervisors, culminating in the Exit Assessment.

Passing the Exit Assessment entitles the trainee to apply for the Fellowship of the Hong Kong Academy of Medicine (FHKAM - Family Medicine); a title signifying a specialist status in family medicine.Nevertheless, this Higher Training period is not mandatory and vocational trainees can opt to exit their programme after 4 years of Basic Training; leaving the extra Higher Training to those who intend to gain recognition as specialists by the Hong Kong Medical Council, and be academic GPs or GP educators.This 6 years programme in Hong Kong is clearly more demanding and rigorous than any other programme in the world. My understanding is that there are very few medical graduates each year per capita of the Hong Kong population, and vocational training is not mandatory to obtain a license to practice family medicine independently in Hong Kong.⁷

So, how can we explain these dramatic differences and justify their varying periods of training? Is it really the longer the better? It is indeed difficult to determine what the ideal training period is for a competent family physician in practice.⁸ Knowledge base is important but it only counts as a low level cognitive competence of a good family physician.⁹ High cognitive competence includes insight into the patient problems, ability to adopt a holistic approach, formation of the best possible management plan within the constraints of all active variables and finally, a practical wisdom, or, "phronesis" as coined by Plato, which cannot be taught from books.

From another perspective, arguably more important in determining the duration of training programmes are the needs of the individual country, the political structure of medicine and the physical locations in which the physicians practice. In Canada and Australia, family physicians may practice in very small remote communities that are literally hundreds of kilometres away from a tertiary referral centre.These family physicians are most in need of skills in acute medicine, resuscitation and stabilization.Having said that, it makes little sense to say that the shortest duration of family medicine training is adopted here in Canada: political expediency is what ultimately dictates this situation.

Perhaps we can justify this brevity with the idea of "phronesis" where vocational trainees are equipped with a basic set of "survival skills" during their residency and then sent out to gather their own pearls of practical wisdom in their day-to-day practice. It is not difficult to observe that in countries where the vocational training programme is a pre-requisite for licensure, the programmes tend to be shorter, so as to ensure a constant supply of family physicians in the medical workforce.

From an educational viewpoint, achieving the competency of an excellent family physician should be the objective for any vocational training programme.However, as adult learner, each trainee will acquire skills and knowledge at a different rate so there should be no fixed duration for any programme.Also, the actual mode and format of knowledge and skills transfer may matter more than the actual duration of training. Unfortunately letting each individual trainee progress at his/her own pace is also impractical.Collective experience from various countries does suggest that three years may be the most practical and efficient period for a vocational training programme in family medicine.