Family medicine in decline?
===========================

* Stanley Lofsky

The concerns that Walter Rosser1 raises regarding the decline in the number of medical students choosing family medicine as a career are appropriate and timely. I would like to expand on some other important factors in this decline. 

First, debt load has become an important factor in students' choice of career. Provincial governments seem to have abandoned the principle that higher education is a national resource to be supported heavily and have taken the hard-nosed view that those who enter a profession should pay the freight up front. Unfortunately, this has affected the socioeconomic mix of medical students and has caused a large increase in expected debt on entering practice.2 To retire that debt as quickly as possible, students are likely to choose specialties with the highest remuneration. 

Another significant factor is the elimination of the rotating internship as a route to licensure. When licensure was being re-evaluated in the 1980s and early 1990s, a third stream other than family practice or specialty certification was discussed. However, this option was not implemented. As expected, pressure was placed on medical students to make early decisions regarding career choice. An unexpected consequence was the development of major barriers to flexibility in career choice, both during and after residency training. Not very helpful are some provincial programs for re-entry into training, whose return-of-service requirements are seen as coercive.

It may not be possible to bring back the rotating internship, but what is needed is the revisiting of a third route to licensure and changes to alleviate the inflexibility that affects medical students, residents and physicians in practice. 

**Stanley Lofsky** Family Physician Toronto, Ont.

## References

1.  1. Rosser WW. The decline of family medicine as a career choice [editorial]. CMAJ 2002;166(11): 1419-20.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTY2LzExLzE0MTkiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY3LzgvODQ1LjMuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  2. Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002;166(8):1023-8.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTY2LzgvMTAyMyI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xNjcvOC84NDUuMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)