Canada is in the middle of a primary care crisis. Fifteen percent of Canadians lack access to a primary care provider, and far more are unable to receive timely access to care.1 This crisis is anticipated to worsen, as two-thirds of family physicians who provide most of the primary care in Canada are expected to reduce practice hours, or retire within the next 5 years. Further, the number of unfilled family medicine residency training positions has increased, and widespread burnout is reported among currently practising family physicians.2-5

A second crisis in family medicine

Consequently, strategies to increase the number of medical students matching to family medicine residencies are being discussed and implemented by Canadian medical schools and ministries of health. Implicit in the current focus on increasing the number of family medicine residents (either by reducing unfilled positions or increasing the total number of available positions each year) is the assumption all students matching to family medicine residencies want to be family physicians. However, this assumption is missing a second crisis in family medicine—the growing number of newly graduated family physicians who may not wish to practise family medicine.

We suspect individuals who would have preferred to train in another specialty are less likely to deliver comprehensive care (eg, care to a defined population of patients across the life cycle for a spectrum of clinical issues) and are at a higher risk of burnout. This mismatch has potential long-term implications for the sustainable delivery of primary care in Canada.

Methods

We used publicly available data on the results of the annual Canadian Resident Matching Service (CaRMS) match between 2000 and 2023 to track changes in supply and training preferences of family medicine residency applicants to provide insight into Canada’s primary care crisis. In the CaRMS match, Canadian medical graduates (CMGs) are matched to a residency program based on their preferred specialty and program ranking, in addition to the program’s ranking of the applicant.6 We examined changes over time in the total number of family medicine residency positions available to CMGs, the number and proportion of unmatched spots, the number and proportion of CMGs who selected family medicine as their first-choice specialty, and, ultimately, the number and proportion of CMGs who matched into family medicine and who ranked it as their first choice specialty.

Key results

How have unmatched family medicine training positions changed over time? The absolute number of family medicine residency training positions in Canada has expanded over time, increasing by 100.9% between 2006 and 2023 (811 vs 1629 positions), while per capita family medicine residency spots increased by 63.1% over the same period (2.49 vs 4.06 per 100,000 Canadians; Figure 1). Since 2015, a growing number of positions have gone unfilled. In the first and second match rounds in 2023, 268 (16.5%) and 100 (6.1%) positions, respectively, remained vacant (Table 1). A long-term examination of family medicine vacancies shows comparable proportions of unmatched positions between 2007 and 2010 (14.4% and 5.6% of spots unfilled in the first and second rounds, respectively, in 2010).

Figure 1.

Total number of available CaRMS family medicine residency positions 2000-2023 compared to the number of family medicine residency positions filled after the first and second rounds of CaRMS matching

Table 1.

Changes in the total number of available FM positions and preference for FM in Canada between 2000-2023

How has the number of family medicine positions filled by a resident who would have preferred to train in another specialty changed over time? Between 2000 and 2014, CMG interest in family medicine matched growth in the number of training positions, while the absolute number of CMGs who matched to family medicine when the specialty was not their first choice remained stable (Figure 2 and Table 1). However, starting in 2015, there was a marked decline in the number of CMGs who matched to family medicine for whom the specialty was their first choice. In 2023, 289 (25.0%) CMGs who matched to family medicine had ranked another specialty as their first choice, compared to 193 (15.4%) in 2015. Collectively, between 2015 and 2023, 2689 (24.1%) CMGs who matched to family medicine had ranked another specialty as their first choice.

Figure 2.

Total number of available CaRMS FM residency positions for Canadian medical graduates 2000-2023 compared to the following: the number who matched to FM and ranked family medicine as their first-choice speciality; the number who matched to FM but did not rank FM as their first-choice specialty; and the number of unfilled FM residency positions after the second round of CaRMS.

Are certain regions and medical schools driving reduced preference for family medicine specialization? While the percentage of CMGs ranking family medicine as their first choice has declined in all regions since 2015, the trend was greater in Ontario and Alberta. Interest in family medicine decreased by 15.8 percentage points in Alberta (39.6% of CMGs ranking family medicine as a first choice in 2015 vs 23.8% in 2023) and by 11.2 percentage points in Ontario (40.2% of CMGs ranking family medicine as a first choice in 2015 vs 29.0% in 2023), compared to a decline of 4.7 percentage points in the rest of Canada (37.1% in 2015 vs 32.4% in 2023; Table 1). Nationally, between 2015 and 2023, 33% of CMGs ranked family medicine as their first-choice specialty. Over this period, McGill University (26.3%), Queen’s University (26.4%), the University of Toronto (26.9%), and Dalhousie University (28.6%) had the lowest percentages of CMGs ranking family medicine as their first choice specialty (Table 2).

Table 2.

Number of CMGs ranking FM as first-choice specialty by medical school: Data from 2000 to 2023.

Discussion

While the number of available family medicine residency training positions expanded between 2000 and 2023, an increasing number of those positions went unfilled after the first round of CaRMS matching. Analysis of 23 years of residency match data highlights that a growing number of CMGs entering family medicine ranked another specialty as their first choice. These findings have important implications.

The growing number of newly graduated family physicians who wanted to train in another specialty might be directly contributing to the current primary care crisis. Canadian data show the number of family physicians working outside comprehensive primary care (eg, working in the emergency department, doing a high volume of minor surgical procedures, etc) increased to 29% in 2021 from 22% in 2013.7 In addition, burnout among family physicians, which contributes to reductions in scope and volume of practice and early retirement, is at record levels.8 While declining preference for comprehensive family medicine and rising burnout are undoubtedly symptoms of a multitude of ailments (eg, rising administrative burden), an unexplored possibility is that the growing numbers of new family medicine graduates who are not preferentially interested in family medicine is contributing to the current crisis.

While many medical graduates who ranked another specialty first but matched to family medicine are likely satisfied practising within the specialty, others may be opting for focused practices (eg, sports medicine) that better appeal to their interests, or if they practise in primary care, they may be at greater risk of burnout due to poor career fit.9 While family physicians with added competencies and focused practices often are meeting patient needs and supporting community-based primary care, an ongoing consideration of the right balance within such practices may be indicated to support access to comprehensive care.10

There may be a role for medical school admissions, curricula, and government policy to influence preference for family medicine specialization. Medical schools play an important role in graduating physicians who will provide comprehensive primary care. Previous research identified several characteristics of medical school applicants that are associated with future specialization in family medicine, and could be used by admissions committees to increase the number of medical graduates choosing to specialize in family medicine.11 In addition, medical school curricula—including exposure to family medicine, promotion of the specialty, mentorship with family physicians, and attitudes of peers and preceptors toward family medicine that form part of the hidden curriculum (ie, the devaluation of family medicine)—are associated with selection of the specialty.12,13

The wide variation in family medicine preferences at medical schools across the country and within provinces, where graduates will experience similar practice environments, highlights that medical school admissions practices and curricula likely vary and influence family medicine specialization choice, which has important implications. If between 2015 and 2023 graduates from the 4 medical schools with the lowest proportion of graduates ranking family medicine as a first-choice specialty had instead met the national average of 33%, an additional 360 CMGs would have ranked family medicine as their first choice, potentially reducing by 62.5% the 576 unfilled family medicine positions during that period. If the national average of family medicine as a first choice was 35% (an absolute increase of 2%) between 2015 and 2023, an additional 513 CMGs would have ranked family medicine first, representing a potential 89.1% reduction in unfilled spots within the specialty.

Variation in family medicine preference by region further supports that government policies, such as models of primary care delivery (eg, team-based care), administrative burden, remuneration, and opportunities to practise, may be influencing the choice to choose family medicine. Most new family medicine graduates report wanting to practise team-based care and be remunerated through non-fee-for-service (FFS) payment models.14 The largest declines in family medicine preference have occurred in Ontario and Alberta, coinciding with policies halting funding for new interprofessional teams and limiting physician entry into non-FFS models.15,16

Implications for potential solutions to the primary care crisis

We recommend careful investment in 3 key areas. First, we advocate for increasing the proportion of incoming medical students who are interested in, and motivated to pursue specializing in family medicine. This could involve both identifying and selecting medical school candidates who are likely to practise comprehensive family medicine and creating designated medical school spots for individuals who will specialize in family medicine, such as Queen’s University’s new direct-entry family medicine program.17 Prior research identified a variety of predictors of family medicine specialization which could be identified and prioritized throughout the process of applying to medical school.11 For example, these include demographic characteristics (eg, being older at medical school entry, growing up in a rural setting, being a first-generation university student), and factors that could be identified during an interview or application review (prior volunteer experiences, having social justice orientation and interests).11

Second, we encourage ongoing curricular reform in medical school and residency to make the practice of family medicine more attractive, including by integrating an emphasis on primary care throughout the curriculum, such as through community placements.18

Third, efforts to improve the experience of practising family medicine, including job-specific factors (eg, better compensation, reduction in paperwork and administrative tasks) and system-level reforms (better integrated care and support, change in models of compensation and delivery of care).19 Such efforts could reduce burnout among practising family physicians while simultaneously encouraging family medicine selection by medical students who perceive a better work environment and encounter more fulfilled family medicine preceptors and role models.20

Conclusion

Findings indicate the number and proportion of CMGs that matched to family medicine but had not ranked it as their first choice specialty have increased over time. Multiple efforts are being contemplated across Canada to increase the supply of primary care providers, including increasing family medicine training positions, reducing barriers for international medical graduates to provide family medicine, and improving the practice and remuneration of the specialty. While such efforts are important, if the sole metric of success is a reduction in the number of unmatched family medicine residency positions, we risk covering up deeper problems in family medicine. If we do not address these challenges, they will threaten the long-term sustainability of the primary care workforce and may lead to future crises in family medicine.

Footnotes

Competing interests

None declared

The opinions expressed in this article are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

This article has been peer reviewed.

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