Is Family Medicine Suffering From a Bad Case of Stigma?

Last month Doctors of BC and the provincial government reached a tentative deal on a renewed physician master agreement — the document that outlines the fee-for-service payment schedule for physicians in British Columbia.

The most significant highlight is the $708-million investment that will increase the average family doctor’s gross billings from $250,000 to $385,000 per year.

The cash flow doesn’t stop there; the province has funnelled additional funding into developing alternative payment methods for newly graduated family doctors. New family doctors can opt to receive a $295,000 salary, plus a $25,000 signing bonus and up to $50,000 in medical training debt forgiveness.

These changes are an explicit effort to address what the provincial government perceives as the main barrier to family doctor recruitment and retention: financing and income.

While the new deal represents a significant investment in B.C.’s health-care workforce, the government has been unwilling to commit to specific goals for the number of family doctors added, or reductions in the number of unattached patients.

For medical students, like myself, the lack of projections is unsurprising. It serves as a tacit acceptance of what’s already known: that the family doctor shortage isn’t going be solved just by throwing money at the problem.

Decline in the appeal of family medicine

Data from the residency application process tells us that finances and the fee-for-service system are not the only reasons why fewer medical school graduates are interested in entering family medicine.

Every year, graduating medical students apply for post-graduate training, or residency, in a process commonly referred to as "The Match.” In 2015, 39 per cent of Canadian medical graduates selected family medicine as their first choice specialty.

By 2022, that number was down to 30 per cent. In the most recent round of The Match, there were 158 family medicine residency training positions for every 100 graduate applicants. Over the past four years, 335 family medicine residency seats have gone unfilled across Canada — and that’s after the recruitment of international medical school graduates.

If the income growth of specialists had wildly outpaced the income growth of family physicians, or the fee-for-service model was a new, exclusive phenomenon to family medicine, perhaps we would be able to draw a clear link between the government’s more than $700-million investment and the recruitment of family physicians. However, the relative incomes of family doctors to specialists has not changed significantly since 2015, and the fee-for-service system is nothing new.

That is not to say that financial sustainability, or lack thereof, plays no role in medical graduates opting for alternative specialties. Nevertheless, it’s obvious that relative incomes and the fee-for-service model are not the only reasons why fewer medical graduates want to become family doctors. Something has changed throughout the past half-decade that has made family medicine markedly less appealing for medical trainees.

‘An elitist tilt towards other specialties’

There is a lot to learn in the first months of medical school. Between learning how to put a stethoscope on the correct way and taking a patient’s history, I managed to pick up on a common understanding that family medicine was viewed as a lesser specialty. It’s an experience shared by Kate DeVito-Porter, a first-year medical student and community outreach co-ordinator of the University of Saskatchewan family medicine interest group.

“When talking about what specialties [students] are interested in, I often hear, ‘Anything but family medicine,’ and that was just in the first months of medical school,” DeVito-Porter said.

Kennedy Lewis, a second-year medical student and secretary of the university’s family medicine interest group, offered a similar sentiment.

“There is always a bit of an elitist tilt towards other specialties.... When I express my interest in family medicine [to other students], it’s always ‘just’ family medicine,” Lewis said.

The easiest explanation for any bias is that the individuals haven’t had enough exposure to the topic. As you might expect, it’s not possible for students a few months into medical school to fully appreciate the complex roles that family physicians occupy in the health-care system. Yet, many medical students who have barely learned how to take blood pressure already have well-established, deeply rooted negative preconceptions regarding family medicine.

“The breadth of the knowledge required to be a good family physician is really undersold,” Lewis said. “Medical students don’t give it the credit that it deserves.”

A limited understanding of what family practice entails is not the only factor contributing to the stigma around family medicine. In my conversations with my classmates, the idea that family medicine is low-hanging fruit with regards to residency applications is a consistent theme.

“It seems that if you want family medicine, you’re settling for what other students consider a backup plan... it doesn’t get as much respect as specialties that are more competitive,” said DeVito-Porter.

The imbalance between supply and demand for family medicine residency positions creates the false perception that one can coast through medical school and still become a family doctor. A lack of exclusivity is intrinsically associated with lesser quality, and it’s a concept that appears to extend to medical specialties as well.

Even when students develop an interest in family medicine, they often have to contend with expectations from their colleagues. As Lewis explains, the idea that family medicine is somehow a lesser specialty creates social pressure for rising students to consider alternatives.

“If you’re doing really well in your classes — to the point that classmates are looking up to you — and then you say you’re interested in family medicine [classmates] are like, ‘Oh....’ It’s almost like they expect you to do something bigger than that.”

Offence as the best defence

The present lack of interest in family medicine is not for a lack of trying on the parts of provincial medical associations and medical school administration. Career-planning seminars often end up somewhere between implicitly hinting at the benefits of family medicine to explicitly extolling its virtues. Medical schools sponsor daylong family medicine symposiums for their first-year students, with the goal of illuminating family medicine as a career choice.

With the bias against family medicine clear and ubiquitous, it begs the question: why are efforts to address the stigma around family medicine falling short? Through my conversation with Lewis, it became clear that the consistent defence of family medicine by medical schools has the unintended side effect of feeding into the negative preconceptions about family medicine.

“I never really considered family medicine to be a lesser specialty, or anything resembling that, until lecturers — who were there to promote family medicine — would come up and say something along the lines of, ‘People say that family medicine isn’t as good, isn’t as important, as other specialties, but that’s not true,’ and I thought to myself, ‘Who says that?’” Lewis said.

DeVito-Porter expressed a similar sentiment, adding that medical schools may be better served by showing the positive, compelling aspects of family practice.

“[They] spend a lot of time talking about how family medicine shouldn’t be seen as ‘less than,’ whereas I think it might’ve been better to talk about the positive aspects of family medicine,” she said. “Having to defend the specialty so much makes students question the validity of those arguments if they already had negative ideas.”

The $700-million question

There’s little room to argue that a stigma against family medicine does not exist within medical schools, or that this stigma hasn’t played a role in our current family doctor shortage. Approximately 335 unfilled family medicine residency seats over the past four years equates to hundreds of thousands of people without a family doctor.

It could, however, be argued that the new funding isn’t targeted at increasing interest amongst medical students, but rather, aimed at making longitudinal medicine — the traditional mode of family practice where you, the patient, can go see your doctor — financially feasible for new and existing family doctors. That argument is not without merit; alleviating the financial barriers will inevitably motivate more doctors to practice longitudinal medicine.

Nevertheless, pre-existing ideas about family medicine pushes those interested in a family medicine residency, and doctors completing a family medicine residency, to look beyond longitudinal family medicine before they ever enter into practice.

The stigma is a significant roadblock in the government’s goal to remedy the existing family doctor shortage. The $700-million question then, is whether increasing the financial incentives to enter family medicine is going to be the cure for the existing stigma. When asked, Lewis doesn’t deny that increasing salaries may help dispel the stigma, but she isn’t entirely optimistic.

“To an extent, yes, [increasing payments] will help, but the stigma is deeply rooted. It’s not something that’s isolated to one medical program or one cause. The solution isn’t going be as simple as [increasing payments],” Lewis said.

Family medicine can be an incredibly fulfilling and rewarding career choice. Unfortunately, many medical students close themselves off to the possibility of entering family practice before they realize this. While family doctors in B.C. are not undeserving of their impending pay raise, we need to acknowledge that throwing money at existing family physicians might not materially move the needle regarding how future medical trainees will view the specialty.

Until medical schools and students address the stigma around family medicine, we will almost certainly continue to experience a family doctor shortage.