HealthyDebate (May 26,2016) Can family medicine meet the expectations of millennial doctors?

Date: May 26, 2016 Author: Wendy Glauser & Joshua Tepper

As more and more baby boomer doctors reach retirement, the first of the "millennial" generation of family doctors are starting to practice or are looking for work. But this new generation has different expectations for their careers than those who are retiring. And it's up to clinics, training institutions and governments to adapt – and quickly – to their changing needs, experts say.

What sets the millennial family doctor apart? In many ways, the newest crop of docs are promoting positive trends in health care, says Milena Forte, a staff physician at the Mount Sinai Academic Family Health Team in Toronto who has written about how training programs can engage young doctors. "There's a real highlighted focus in medical schools now on patient safety and social accountability – these are values young doctors really care about," she says.

Young doctors have also been encouraged to think more about work-life balance – a major value for the millennial generation in all fields, and something that's being discussed more in medical schools. "Our teachers have been telling us, 'You need to take care of yourself.' That's a really positive message because they've been practising family medicine for a long time," says Lindsey Sutherland, who studied medicine at the University of Alberta and completed her family medicine residency at McMaster University in 2015.

And when it comes to what they want out of their careers, Forte says young doctors desire more mentorship and further training than previous generations of family doctors, and they're more attracted to collaborative work.

But there are concerns that too few collaborative, team-based job opportunities are available. Others worry that the greater specialization trend among the younger generation is at odds with the more generalist needs of family medicine.

Young doctors want to practice in team-based models

Medical schools have highlighted team-based care as a new pillar for family medicine, says Ivy Oandasan, a professor of family medicine at the University of Toronto. "I wasn't really exposed to an alternative [other than a team-based model]," says Sutherland. "Most of my peers learned in a Primary Care Network or Family Health Team."

Team-based models allow more work-life balance and specialization. And they're also attractive because new doctors "see team-based care as providing better care and better access for patients," says Laura Bourns, vice president of the Professional Association of Residents of Ontario and a family medicine resident at the University of Ottawa.

The teams that young doctors are exposed to usually include more than physicians. "We take classes now with nursing and physiotherapy students," says Ali Damji, chair of Ontario's Medical Student Association and a third-year medical student at the University of Toronto. "We're a lot less silo-ed than we used to be."

Unsurprisingly, "there is no interest in practising in a solo practice model," says Oandasan. In a 2015 survey of 650 final-year residents from 16 schools she conducted for the College of Family Physicians of Canada, 59% said they were 'not at all likely' to work in a solo practice, while 21% were 'somewhat unlikely.' Only 9% said they were somewhat or highly likely to work in a solo practice. (The survey hasn't been published online.)

Here's the rub: "If you look at the kind of models that people are retiring from right now, a lot of them are solo practices," says Oandasan. In Ontario, meanwhile, government funding for team-based models has slowed.

In 2015, the Ontario government reduced the number of new entrants who could join Family Health Networks (FHN) and Family Health Organizations (FHO) (associations of physicians that lead Family Health Teams) from 40 a month to 20 a month (or 480 a year to 240 a year), largely due to the costs of these programs. New entrant positions for FHOs and FHNs were also limited to underserviced areas. There are 500 family doctor graduates each year, according to the Ontario Medical Association.

Sutherland was affected by the policy change firsthand. When she began looking for family physician openings in rural Ontario in 2015, she found she couldn't find a family health organization that could access government funding to expand their group. She is currently working as a locum family physician at a Family Health Team in Chatham, Ontario, while also providing care to patients in the hospital and covering obstetrics and emergency medicine duties.

Many of her colleagues are in a similar boat. Some are still doing locums while "others have gone to other provinces than Ontario, which is unfortunate when this province subsidized their education."

David Jensen, media spokesperson for the Ontario Ministry of Health and Long-Term Care, says the government has responded to young physicians' calls for greater funding for team models by launching the New Graduate Entry Program (NGEP), "as an entry mechanism for new graduate physicians in to the Family Health Network and Family Health Organization models in areas that are not designated as high needs." But critics of the program, including the Ontario Medical Association, say the NGEP isn't a solution because it doesn't provide as much salary support and puts too many restrictions on young doctors who choose that model. "Because of those problems, there has been virtually no uptake of the NGEP," says Dr. Virginia Walley, president of the OMA.

Tension between desires of young doctors and needs of rural communities

On top of the lack of team-based opportunities, there's another tension with millennial doctors and the type of work needed in rural communities.

Doug Myhre, a family physician who co-established a rural-based family medicine residency training program in Alberta, worries that too few young medical trainees are willing to work in rural areas.

There's been a general trend in family medicine toward specialization, and millennials who have taken additional training might not be interested in working as generalist doctors in rural areas. "The new generation is being mostly trained in urban areas, by people who are working in smaller and smaller niches of family medicine," says Myhre. Indeed, Forte says that many of the young family doctors she works with are taking an extra year of residency, specializing in maternity care, sports medicine or palliative care, for instance.
Specialization can allow doctors to command higher incomes, but a big reason for the trend of extra training is that young doctors want to feel highly confident in their knowledge and skills. "There used to be a joke in medicine that you would see one [procedure], do one, and then teach one," she says. "Today, students might say, 'I've only seen 10 of those procedures, I don't feel comfortable doing it.'" Millennial doctors "require a lot more clear structure and frequent feedback on how they're doing," says Forte. This sets them apart from boomers, as well as the more do-it-yourself Gen-Xers. But it isn't easy for underserved areas to provide the senior mentorship support young doctors crave.

Then there's the push for having a life away from work – another potential strike against rural medicine. "We've focused a lot on work-life balance in medical schools, and I wonder if that's been taken too far. There's this idea among younger doctors that when I'm working, I'm working, when I'm off, I'm off," says Myhre, but that might not be realistic in many areas. "If someone comes to my door at 10 pm with a wound, I'll stitch them up."

Rural medicine clerkships and residency programs can help expose learners to all areas of family medicine. Exposure to rural medicine can also highlight the benefits of what Myhre calls "work-life integration": short commutes, and being able to see family and friends over lunch, for example. And they can help young doctors practise using their knowledge base, as well as researching or consulting with others, to treat patients with symptoms or diagnoses they might not be as familiar with. But there still aren't enough of these kinds of programs, says Myhre, whose program accepts up to 30 residents each year but receives around 200 applications.

How communities can attract millennial family doctors

Recognizing the new generation's preferences for mentorship, specialization, and work-life balance, many communities are finding creative ways to meet these needs.

At the Georgian Bay Family Health Team where Damji did his third-year rotation, family practices in surrounding areas are networked together so that doctors can be on call for a wider area and work fewer call shifts overall.

In Marathon, Ontario, Newberry's group has agreed to take a pay cut in order to have more time. There, eight doctors work for a Family Health Team that is funded by the government for six positions. "You don't want to feel like you're putting stress on your colleagues' shoulders when you're sick or dealing with a family issue," she says.

The ability to take time off with short notice is something that will become more and more important, Newberry believes. Physicians in their 40s already find themselves taking care of young children as well as their aging parents – a situation that's expected to become more common as people have children later in life.

Meanwhile, physicians entering practice now are "much more likely to have a spouse who has a fairly high level of post-graduate education," Newberry points out. While male doctors who are retiring may have been able to devote themselves to their practice because "someone took care of everything on the homefront," the millennial doctors expected to take retiring doctors' places are unlikely to have a stay-at-home spouse, she adds.

Forte suggests another way small communities can attract young doctors is to highlight the informal mentorship opportunities. "There's often an attitude of 'call me if you run into trouble or if you need something' in small communities," says Forte, but it's "perhaps not advertised" as much as it should be.

Indeed, in a survey that compared differences between communities that were successful in recruiting doctors and those that weren't, one of the key aspects common to the successful communities was informal and formal mentorship programs, says Oandasan. Provincial governments can support this by paying doctors to provide mentorship in rural areas, as Manitoba has.

Rural communities that have team-based models are also promoting how their set-up allows for greater specialization and learning beyond residency. Rob Wedel is a senior family doctor and co-founder of a team-based clinic in Taber, Alberta, where numerous other providers, including registered nurses, a dietitian and mental health nurses, work with physicians to provide care in the clinic as well as meet the communities' emergency department, mental health and long term care needs. "There's such a variety of care to become involved in," says Wedel. "There are doctors who like to do a lot of obstetrics and others that don't want to do any obstetrics, and those kind of possibilities exist when you have a large group and you're providing many services."

As Forte sees it, the expectations of young family doctors are understandable, and doable. "We have to preserve and teach the core values of family medicine," including continuity of care and building trusting relationships with patients, she says. "How they enact those values, that's going to change, and we need to respond to that."

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