Who wants to be a family physician?

This quote comes from the 33rd William Arnold Conolly Oration given by Max Kamien in Melbourne, Australia, in 2004.1 Dr Kamien was a friend of the late Dr Bass, who had described his first venture into general practice this way. It is a feeling that all family physicians know well, sometimes even after many years in practice. All developing countries have struggled with a declining primary care physician work force in the past 2 decades.2-4 In Canada, the proportion of students choosing family medicine fell from 44% in the early 1990s to a low of 25% in 2003.5 Since then it has risen to 31% (in 2008 and 2009) but has failed to reach the goal of 45% set by the College of Family Physicians of Canada.6 Consequently, many Canadians still do not have their own family physicians. Many factors have contributed to medical students’ declining interest in family medicine careers, including the lower status and income of family physicians, the effect of debt accumulated during medical training, and the influence of the “hidden curriculum” during medical school.7-9 Over the past few years, Canadian Family Physician has published high-quality, thought-provoking research examining these trends. This issue features such a study by Vanasse and colleagues (page e216), who use data from the 2007 National Physician Survey to examine the factors influencing students to choose or not choose family medicine as a career.10 They studied students in the preclinical and clinical phases of their training and discovered that less than a third of either group hoped to pursue family medicine. Not surprisingly, students looking for shorter residencies were 9 times more likely to want to pursue family medicine. Other factors that positively influenced preference for a family medicine career included the desire to be involved in public health and the possibility of flexible work hours. Conversely, those students interested in high-income specialties or who expected to develop research careers were less likely to prefer family medicine. In the January 2011 issue of Canadian Family Physician, Woloschuk and colleagues attempted to debias the “hidden curriculum” (which looks negatively upon family medicine).11 They examined students’ academic performance and found that those choosing family medicine performed as well as those who chose other specialties. These results debunk one of the themes of the hidden curriculum: that students choosing family medicine are less academically accomplished. Education in our medical schools remains primarily disease-oriented in its approach, and most of the teaching in the preclinical and clinical years is still done by specialists other than family physicians. Along with the pernicious effects of the hidden curriculum, perhaps medical students, encountering family medicine in the later stages of their training, find that the patients don’t have anything they learned about and choose instead the kind of diseaseoriented practice they are most familiar with. Family medicine differs from specialty medicine in its approach to the patient, and it demands the most we have to offer. As McWhinney has so profoundly said, family medicine is fundamentally different: it is the only discipline to define itself in terms of relationships, especially the doctor-patient relationship; family physicians tend to think in terms of individual patients, not generalized abstractions; family medicine is based on an organismic rather than a mechanistic metaphor of biology; and family medicine is the only major field that transcends the dualistic division between mind and body.12 The idea of attracting the best and brightest and challenging them to consider family medicine—not just because of its humanistic challenges but because of its unique intellectual challenges—is appealing.13 But more is required. It is crucial that family physicians play a much greater role in developing the curriculum, as well as in teaching in the preclinical and early clinical years. Only then can we show students the tremendous appeal and importance of being different. Only then can we prepare them properly.