Choosing primary care: why is Canada different than the US?

It is a slow night on call at the hospital, and I came upon an excellent article called “Why I’m becoming a primary-care doctor” in which a medical student at the University of Pennsylvania discusses her choice to enter a family medicine residency. I was shocked at two aspects of the story: first, that only 12% of graduates in the US residency match ended up in primary care specialties, and second the disdain which the author feels many of her classmates and some of her preceptors have for family medicine.

In Canada in 2013 (the year I matched to residency), 37% of all graduating medical students matched to family medicine as their top choice of programs. Where I trained, at the University of Toronto, home to some of the most highly sub-specialized programs and staff physicians in the country, 33% of students chose family medicine as their top choice. And that doesn’t include pediatrics, from which many graduates will go on to become primary care pediatricians. (In Canada, internists are not generally considered primary care doctors, in contrast to the US).

In terms of attitudes, I have personally never heard any classmates, residency colleagues, or staff doctors echo the sentiment that “on family medicine, the intellectual rigor is not there”. And this article made me wonder what is fundamentally different between Canada and the US systems whereby primary care medicine is viewed so differently. While I cannot claim to know the answer, I have some hypotheses I would like the throw out there.

Many of the academic (and community) hospitals in Canada have family care practices based physically at the hospital (or close by). This fosters stronger relationships between subspecialists and family doctors. If a complete separation between family doctors and hospital-based specialists occurs, there is a greater risk of one group looking down on the other. And since in the US the differential in salaries between specialists and family doctors is enormous, it is not surprising that the general public, and the specialists themselves sometimes think that “a monkey could [practice general medicine]”. Also, since historically one-third to one-half of medical students go into family medicine in Canada, I would presume nearly all Canadian doctors have friends in the specialty and gain an appreciation and understanding for the job they perform.

During my time on the general internal medicine ward, anytime a patient was admitted with a complex medical history or in whom the diagnosis was unclear, my first act the next morning was to personally speak to the patient’s family doctor to gain further insight into the issues at hand. And every time I discharged a patient, I instructed them to see their family doctor the next week so that their GP knew what had happened to them, and to make sure the patients were coping well at home. I have no data to back this up, but I believe patient care is better because patients have access to excellent family doctors that provide continuity of care.

Overall I am glad that I work within a system with a strong and well-respected force of primary care physicians fostering long term relationships with their patients, treating a wide range of illnesses, and taking charge of preventative care where some of the biggest gains in the health of our population can be achieved.



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