Why did efforts to expand Canadian family medicine residency training to three years fail? An education policy analysis

Context: Family physicians in Canada have one of the broadest scopes of practice and shortest postgraduate residency training periods among high income nations. In 2018, the College of Family Physicians of Canada (CFPC) reviewed Canadian family medicine training and determined it must evolve to meet contemporary societal needs. Resulting recommendations included an expanded competency profile and a corresponding expansion of residency training to three years. However, evidence is not the only determinant of policy change and residency expansion ceased in November 2023.

Objective: Understand the various influences which impacted residency expansion policy efforts

Study Design and Analysis: Policy analysis of publicly available materials.

Dataset: Data are public materials including reports, open letters, publicly available recordings of annual member meetings, news coverage, social media discussion. 3I+E framework analysis describes and explains how this education reform arrived on the agenda and why implementation ceased.

Instrument/Outcome Measures: Using the 3I+E policy framework, we discuss examples of the Interests, Institutions, Ideas, and External factors which shaped this recent trans-jurisdictional education policy reform initiative, paying particular attention to the forces which coalesced to result in termination of the reform effort.

Results: There are conflicts at each level of the 3I+E framework. Primary care access challenges have been exacerbated since the Covid-19 pandemic. This set the stage for political involvement and competing discourses about how family physicians should be trained, remunerated, and deployed. Conflicting explanations about the origins and solutions to the problem of access played out in debates about residency expansion, alongside rhetorical arguments about the quality and type of evidence needed to justify education reform. While political, professional, and regulatory interests interacted in public discourse, the voices and interests of patients were absent. The autonomy and remuneration of physicians was prioritized in many discourses opposing residency expansion.

Conclusions: This presentation documents multiple conflicting interests which coalesced in the cessation of CFPC efforts to expand family medicine residency in Canada. This analysis demonstrates the challenge of education reform and the importance of aligning interests, institutions, and ideas to initiate primary care policy change.