The current primary care crisis in Canada is well documented.1,2 The addition of family physician residency positions has, unfortunately, not been matched by applicant interest.3 In 2023, 268 family medicine (FM) positions were unfilled across Canada after the first iteration of the Canadian Resident Matching Service match,3 a record high. This number remained high the next year, with 252 spots unfilled after the first iteration of the 2024 match.3

As FM educators we have been concerned about the declining interest in FM and the attendant effects on the health care workforce and the health of our communities. We sought to clarify reasons for this decline from the unique perspective of residents at the start of their FM training. This commentary will reflect on 2 sources of data collected through the Family Medicine Longitudinal Survey (FMLS) administered by all FM residency programs on behalf of the College of Family Physicians of Canada to all residents within 3 months of the start of training (T1) and again within 3 months of graduation (T2). We examined T1 data,4 as it is the most proximate to residents’ experiences in medical school and their decision to choose a career in FM. Our first source of data is national in scope and includes FM training sites between 2014 and 2023.4 The second source of data was supplementary questions we added to the FMLS (T1) at the University of Toronto (U of T) in 2023 and 2024. All incoming U of T residents were asked their top reasons for choosing a career in FM (Table 1) and their top concerns (Table 2) (n=299, 85% response rate). While our data capture the perspective of graduates who have chosen to pursue FM, it would be equally instructive to explore the views of those who chose another specialty.

Table 1.

Most influential considerations in choosing an FM career: “What influenced you the most to choose a family medicine career? Please rank top 3.”

Table 2.

Top concerns about choosing FM as a career: “What are your top concerns when choosing family medicine as a career choice? Please rank top 3.”

We offer an FM educator lens on the results and possible educational solutions to address the crisis in FM.

Top influences when choosing FM as a career

Residents were presented with a list of options and asked to rank which of these influenced them most to choose a career in FM (Table 1). The top reason was perceived flexibility. This might mean flexibility in scope of practice, working hours, setting, or geography. Others have also reported that practice and lifestyle flexibility rank high among Canadian medical students choosing primary care specialties,5 and that exposure to FM mentors can promote the flexibility of a career6 and lifestyle7 in family practice.

The second most influential reason to choose a career in FM was a desire to have long-term relationships with patients and families. This motivation has been identified in other studies.5 We must continue to highlight the joy and magic of these relationships to our learners. An attempt to incorporate early and longitudinal experiences in primary care should be made whenever possible, as these experiences increase the proportion of students choosing primary care.8-11 These experiences could be incorporated through patient panels, longitudinal experiences in preclerkship, or longitudinal integrated clerkships.8-11 New medical education models, such as the Queen’s–Lakeridge Health MD Family Medicine Program, which is designed to accomplish all the medical school program learning objectives through the lens of FM and primary care, hold promise.12 This Queen’s University program provides students with immersive longitudinal clinical experiences from year 1 in a variety of family practice settings and transition into dedicated postgraduate FM residency positions at Queen’s University.12 Toronto Metropolitan University School of Medicine will welcome its first class of medical students in September 2025 with a focus on primary care.13 Over the next few years, additional new Canadian medical schools are slated to open for enrolment, including at Simon Fraser University in Burnaby, BC,14 the University of Prince Edward Island in Charlottetown, PEI (as a regional campus of Memorial University of Newfoundland),15 and potentially York University in Vaughan, Ont.16 These schools aim to take a community-based approach, with a focus on relationships, social accountability, and enhanced primary care opportunities.

Experiences within FM settings during medical school was the third highest-ranked factor. Primary care clerkships that are longer, of higher quality, that expose students to a wider scope of primary care practice, and that occur within an institutional climate that is supportive of primary care are correlated with more students choosing a primary care specialty.17 Training on regional campuses or providing primary care experiences in rural settings also correlates with a larger percentage of graduates entering primary care.18 There are great opportunities to embed principles of family-centred community-based primary care from the earliest foundations in our new schools and to fortify existing programs.

Exposure to FM role models was the fourth reason for choosing an FM career. Early exposure to experiences10 and positive role models in primary care have been shown to increase trainees’ interest in a career in FM.6,7,9,11,19 We need to continue to identify, prioritize, and safeguard these experiences and role models in our current challenging primary care climate, at a time when our FM teachers are overextended, underresourced, and exhausted.

Top concerns when choosing family medicine as a career

The top 4 concerns when choosing a career in FM related more to health care system challenges than to educational issues (Table 2). Data from thousands of incoming FM residents across the country over the past 5 years tell us that 9 of 10 are proud to become family physicians.4 However, recent trends indicate that residents increasingly believe that family physicians are undervalued by the public and the government. While most FM residents report believing that FM is respected by patients, it is concerning that this perception has decreased appreciably over time. Even more striking is that almost two-thirds of FM residents in Canada reported feeling that the government does not perceive FM as essential to the health care system. These concerns can be best addressed through political action. As practising family physicians, we can advocate for change and be positive role models for our future colleagues.

The concerns of perceived lower status than specialists, little respect for the expertise of family physicians, and negative messaging about FM during medical school point to the hidden curriculum that devalues the generalist expertise of family doctors20,21 and can decrease student interest in FM.11 Conversely, ensuring an institutional climate supportive of the specialty of FM and creating an atmosphere of acceptance of the pursuit of primary care as a career increase an institution’s percentage of medical students entering primary care.17,18,22 Early exposure to FM teachers in preclerkship courses and embedding generalist theme leads for curricular review and oversight in our medical schools are educational strategies to address these concerns. FM role modelling and mentorship must continue to be widely available and promoted. Expressed concerns regarding managing uncertainty, complexity, and ambiguity in FM serve as a reminder to ensure that we highlight the value of adaptive expertise in our curriculum and clinical settings. These experiences are necessary for learners destined for any specialty and can help to address the hidden curriculum that devalues FM, and serve as an opportunity to highlight the role of family physicians as specialist generalists.20

Students make their career decisions at various stages before and during medical school. The results of our survey suggest that most students make their decision to pursue FM during clerkship while on their FM rotation (Table 3). Career intentions are not fixed and change mainly during clinical training, supporting the influence of clinical experiences on career-related choices.22 Therefore, ensuring medical school curricula expose students to FM role models and excellent experiences at all stages is crucial.

Table 3.

Timing of decision to pursue FM career: “When did you decide you wanted to be a family physician?”

Educational solutions: a call to action

Both educational and health care system solutions are necessary to reverse the trend of reduced interest in FM as a career. Based on both the positive influences and the concerns that FM residents identify, we summarize the following curricular and educational strategies to preserve and revive interest in FM as a career choice.

Effective strategies in our current programs include the following:

longitudinal and early FM experiences in medical school,8-11

early exposure to FM teachers in preclerkship courses,10

generalist theme leads for curricular review and oversight, and “generalism” courses,23

FM role modeling and mentorship,6,7,9,11,19

educational experiences focusing on managing uncertainty, complexity, and ambiguity,20

training on regional campuses or providing primary care experiences in rural settings,

exposure to a wider scope of primary care,9,17 and

addressing the hidden curriculum that devalues FM.11,21

These educational solutions might promote interest in and elevate the perceived value of FM among all trainees.

In addition, we must consider medical school admission policies and ensure we are selecting candidates from diverse backgrounds who will commit to delivering socially accountable primary care to our communities in need.22,24 Family doctors must be included on these selection committees. Applicants who identify an interest in primary care, grew up with a rural background, and are older are thought to be more likely to enter primary care; however, the literature is insufficient to recommend best practices.24 New primary care–focused streams and medical schools, both in Canada and abroad, hold promise in terms of graduating more primary care doctors and optimally preparing graduates for their future in FM.25,26 Finally, creating a political and educational climate that respects and values family doctors as specialists in generalism who deliver patient-centred community-adaptive care is imperative to promote interest in FM.27

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.

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This article has been peer reviewed.

Cet article se trouve aussi en français à la page 392.

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