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First Five Blog: Should You R3?

By Dr. Shan Lu

If you are in your second year of residency, you may be considering whether or not to do an R3. I had the same question in my second year and, to some extent, still do. This blog shares my personal story and links to the CFPC website for additional information about their Certificate of Added Competence (CAC) program.

First, the story. I became interested in the Care of the Elderly (COE) when I was in my second year of Family Medicine Residency. At the time, I was already five months pregnant with my first child. I had decided that I was interested enough in the field of COE that I would like to specialize in it, so I went ahead and applied for an R3. I was accepted and the University of Alberta even agreed to a deferred start date so I could have my maternity leave as planned.

As my deferred start date drew closer, I became increasingly aware of the difficulties I might face in balancing residency and a child under one year old. I wanted to get working (part-time at that). I had previously established enough connections in the COE field that helped me to land a related part-time position, and I’ve been working at a job I love, and learning in the field, since. Occasionally, I’ve consider returning to do a 6-month accelerated R3 in COE—mostly so that I could have the CAC behind my name.

Now the details. The CFPC currently only allows those who have completed an R3 program in the areas of COE, Sports and Exercise Medicine (SEM), Family Practice Anesthesia (FPA), Palliative Care (PC), and Emergency Medicine (EM). Newly approved domains are Addiction Medicine and Enhanced Surgical Skills.

The CFPC website states they are evaluating how people who have on the job learning could apply and be qualified for a CAC within their chosen field. For example, Emergency Medicine (EM) is a bit different, as you could gain enough experience on the job to then challenge the exam or to go through an R3 EM program. More details are available on their website:

Everyone’s experience will be different but, here are some factors you may want to consider when deciding whether or not to do an R3:

  1. Your stage of life,
  2. If you can do the same job without the extra year or if the extra year is crucial to get into the field you like,
  3. How easily you would be able to obtain the CAC if you don’t do the R3 right after your R2 year.

Hope this has been helpful.

Dealing With a College Complaint – Putting It Into Perspective

By Dr. Shan Lu and Dr. Kaili Hoffart

Patient A was admitted due to weakness, falls, failure to thrive. He was still driving prior to admission. However, his cognitive screen revealed red flags about his ability to drive safely. After discussion with the patient, the attending physician filed a form to Alberta Driver Fitness Monitoring. Patient A complained to the CPSA, outlining that the cognitive screen was not warranted and felt that the conclusions made regarding driving safety were erroneous. The complaint was initially rejected by the CPSA complaint director. The patient then appealed to the Complaint Review Committee (CRC). The CRC decided to review the complaint and had asked the physician to submit a written explanation. The physician contacted the CMPA and was assigned a case physician who helped to review and explain the CRC process. The attending physician then wrote a letter of explanation in reply to the patient’s complaints. The letter, all communications with the CPSA pertaining to this case, and all letters from patient A to the CPSA were reviewed by the CMPA physician. All this was then forwarded to a CMPA lawyer for review. The attending physician met with the lawyer to provide more information. The CMPA lawyer then modified the letter from a legal perspective. When the final draft had been approved by the physician, it was hand delivered to the CPSA prior to deadline set by the CRC. Throughout the process, the CMPA was responsive and reassuring.

It is almost inevitable that at some point a disgruntled patient will express their views to the college. Approximately 60% of all practicing physicians will have a patient complaint registered against them at some point in their careers.

A recent article entitled “Complaints Should be Something to Smile About” in The Medical Post written by Donalee Moulton highlights just this:


Patient complaints strike fear into most physicians. The deputy registrar of the College of Physicians and Surgeons of Saskatchewan (CPSS) would rather they bring a smile to doctors’ faces. “My goal is that when a physician receives a complaint to jump up and say, ‘Yes! This is a chance to improve my practice,’” Dr. Micheal Howard-Tripp told the Medical Post in an interview.
There is no room for complacency when it comes to complaints, he added. Approximately 60% of all practicing physicians will have a patient complaint registered about them at some point in their career.

Dr. Howard-Tripp recommends doctors first read the letter discussing the complaint. Then, he said, they should put it down. “Let your emotions settle.”

Although it may sound counterintuitive, it is also helpful to talk with colleagues. “When a physician gets a complaint, they tend to hold it very close to their chest. My recommendation would be to share it with others. Complaints often reflect systemic problems,” noted Dr. Howard-Tripp.

He also suggests doctors take the initiative and offer up a solution to the problem highlighted in the complaint. For example, if a doctor reviews their patient notes and concludes they were inadequate or incomplete, it can be helpful to acknowledge this and undertake a continuing medical education program directed at this practice area.

The solution may be acceptable to the patient and help resolve the complaint, especially if the issue is not seen as serious. Even if the solution is not accepted, the physician’s effort to resolve the issue will be well received by the regulator. That would stand in their favor, said Dr. Howard-Tripp.

In an article Dr. Howard-Tripp wrote on the issue in the most recent issue of the CPSS magazine, DocTalk, he stressed that honesty – with yourself – is also the best policy. “Honestly reflect upon the communication style you used. At times we physicians don’t realize that our communication style is not effective for certain patients. If there are improvements you could make in your communication, acknowledge these and the opportunity to improve.”

Physicians must also recognize that each complaint stands on its own and defaulting to the status quo in response to a complaint is not acceptable. Dr. Howard-Tripp points out that many doctors, for example, respond to complaints by stating “it is my usual practice.” “That doesn’t help us,” he noted. “We want to know what happened in this situation. Your response needs to satisfy the patient.”

Receiving a complaint can mirror the process of grief. Physicians will frequently go through stages of shock, anger, rejection and acceptance. It may be helpful to have professional advice along the way. Dr. Howard-Tripp encourages physicians to speak with the Canadian Medical Protective Association. “It’s better to correct any mistakes at the beginning.”

Do not hesitate to reach out to the CMPA early on in this process to request assistance and guidance. Their guidance and support not only helps to ease anxiety but ensures all necessary steps are followed. For further information or questions regarding CMPA assistance and legal issues, the Association can be reached at 1(800) 267-6522. If you call, you will be placed in direct contact with a physician advisor who can provide confidential medical-legal advice.

The First 5 Years

Medicine is many things. It is constantly challenging, humbling when you least expect it, stressful within an instant and rewarding in circumstances you would never anticipate. The ways in which medicine can surprise, and even fool you, is particularly evident in a physician’s first five years of practice.

The early stages of medical practice are met with beaming optimism as a long educational journey finally comes to a close. Despite this enthusiasm forging a new path can be outright terrifying at times (okay maybe even all the time). One often longs for the patiently observing staff to come forth from the shadows and peer over their shoulder once more.

One of the best ways to get ready for this exciting new frontier in one’s career is to quite simply—prepare. It may sound obvious but preparation can truly make a difference when starting practice and this most important step should start well before you even enter practice. While physicians are well educated for clinical roles and responsibilities, it’s all the other stuff that many of us tend to ignore which requires attention as we commence practice.

So Where To Begin…
Getting one’s privileges and licenses in order is one of the most time consuming and paper-work heavy aspects of the process. Considering that this has fun written all over it…many seem to stall on this opportunity at form completion nirvana. Yes, it will take forever to complete all the forms, and having them reviewed and signed off will take even longer than eternity, so it’s best to start as soon as you can!

The Alberta College of Family Physicians First Five Years Committee has a link to all the general privileges and licensing steps required for Alberta (applicable to FRCPC colleagues as well). This may be a good place to start to get one’s bearings on the process. Try to cover off all the forms and registrations at once as most require similar documentation and you won’t have to worry about it later should the need suddenly arise. (Link:

Other important aspects to set in place include establishing your professional team. It is imperative to find a lawyer for your practice basics (for example, document notarization, establishing your professional corporation, etc.). In addition, finding a good accountant will be essential as you move through your early years of practice when there are a lot of financial changes occurring. A financial planner will also be crucial in this regard.

When searching for such professionals its best to ask around, as your colleagues will know competent professionals with experience in medical practice. Since physicians have unique accounting and legal needs, look for someone who has worked with several physicians, and has an interest in this area. Having trusted professionals in place from the start will help you ease into early practice.

Another essential element of early practice is having mentors. There are assigned mentors throughout training, often a primary preceptor or a program director; but what happens when you finish? Who will that be now? Unless you’re proactive, you might find yourself without a mentor. Having a more experienced mentor to talk to and advise you through the more complicated parts of medicine is of immense value. Inevitably challenges will arise, often not directly clinical, and having access to a trusted mentor you can call or text to ask questions can really make all the difference. Soak in the knowledge and experience of others.

Furthermore, whether with a mentor or a peer, when you confront a difficult or stressful situation try to debrief. It’s important to have a group of trusted peers or practice colleagues you can talk to when you’ve simply had a bad day. Knowing that others have gone through similar challenges or hearing their words of comfort can make a stressful situation manageable, or help to process a difficult experience.

Another important principle in early practice is “err on the side of asking.” If you’re not sure about how to manage a dilemma or scenario just ask. I often find that physicians are reluctant to call expert colleagues, designated lines or even CMPA. These services are there to help you, and even if you think your question is inconsequential or small, do not hesitate to call them. At minimum it’s a learning opportunity and at best, it’s rescuing clinical or legal advice on how to manage a challenging situation.

When establishing your practice, try to weave variety into your day to day work. Doing five days of clinic a week can be very draining and may burn you out. Having even a half day for an area of interest, procedures, or an administrative role can help keep your work schedule varied and fresh. Those with more diversity in their practice, and utilizing their full set of skills, are often more satisfied professionally. Furthermore, once you commence practice you can lose your skills very quickly if you don’t use them, so capitalize on opportunities to participate in many areas of interest early on.

It is essential for early career physicians to be engaged and involved. There is already so much on the go during this phase, and just keeping afloat with clinical medicine can be exhausting but in today’s environment new doctors also need to have a strong voice and participate in whatever ways interest them. If you’re interested in education, take on teaching roles, or if you have an interest in policy or advocacy look for leadership and administrative opportunities. Expand your scope beyond just routine clinical duties from the start, and it will enrich your career.

Do stuff that is not medicine. I don’t think I could close this article without also mentioning that you should have a life outside of medicine. The first five years are often clinically heavy, but be cautious not to burn yourself out as soon as you start. There is no need to pick up every last locum or every open call shift. Learn to say “no.” Spend time with your family and friends, travel, stay active, participate in activities you enjoy, or even take on new hobbies—because before you know it you’ll be the one looking back on your first five.

Dr. Jalil grew up on the Saskatchewan Prairies. She obtained her undergraduate and medical degree in Saskatchewan before moving to Calgary for residency. After completing her residency in Family Medicine, Dr. Jalil did an R3 year in Women’s Health.

Dr. Rabiya Jalil, BSc, MD, CCFP
Primary care for complex and vulnerable populations, surgical assisting, and women’s/ sexual health. Dr. Jalil serves on a number of committees and also takes an active role in medical education, teaching at the University of Calgary and as the Medical Director of the Alberta International Medical Graduate Program.

Friedberg, Mark W. et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. RAND Corporation, 2013,

Article originally published in Vital Signs magazine.

Dying With Assistance

“Death comes for all of us…Most lives are lived with passivity toward death-it’s something that happens to you and those around you…but [we] trained for years to actively engage death, to grapple with it…and, in so doing, to confront the meaning of a life…The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” (Kalanithi, 2016)

In his book, When Breath Becomes Air, Paul Kalanithi, a senior neurosurgical resident faces his own mortality after years of staving off the death of his patients. His book raises the question: What is our role in patient death as a physician? With modern advances of pharmacology, oncologic treatments, surgical technology, and medical devices, it would appear that we are trying to prevent death at all costs. But what about those costs?

As a family physician with a special interest in palliative care, I witness the frustration that can occur when we are faced with a patient with an incurable illness. As a result, we try to manage and reverse it. Take for example the case of Jane, a 50 year old woman with advanced early-onset dementia who is diagnosed with a biliary duct obstruction from a pancreatic cancer. Is there a fixable problem? Yes. But should we fix the problem? No one asks the latter question and Jane is rolled into the OR. There’s also Doug, a 67 year old man with lung cancer who is admitted for a pneumonia that is not responding to oral antibiotics. He is admitted to the ICU for vasopressors to keep his blood pressure up and IV antibiotics to try to fix the pneumonia. Doug passes away 3 weeks later, in ICU hooked up to 2 monitors, 3 IVs, 1 central line, and a BiPap machine. These interventions may have prolonged the lives of Jane and Doug, but would they have personally chosen them if they were made aware of the price to pay for the time gained?

What if death is not the enemy? What if anything that affected both the quality and quantity of life were made the enemy. This could include both diseases and our cures. Tom is an 85 year old man with a severe ischemic stroke resulting in sustained hemiparesis and difficulty swallowing. He is at high risk of contracting aspiration pneumonia if he is allowed to eat, and so he is denied any food for his safety. Tom asks if he can eat a hamburger. A family conference is held, and his family is made aware of the risks of his request. Tom enjoys multiple homemade meals before he passes away a few days later. His family wonder if they did the right thing and question the doctor’s decision to allow him to eat, but Tom already said what he wanted. He wanted to live until he died. And to him, living meant having a hamburger with his family.

Just this past week, a patient with liver cancer was admitted for a viral pneumonia. His distressed family requested something more for his dyspnea as they watched him struggle. As he reaches out gasping for air and restless from hypoxia, the family is told there is nothing more than can be done without risking his life.

A physician must really ask themself, are we truly battling against death? It may happen regardless of what is done, but it is our patient’s lives that we can truly impact. Near the end of the journey with a life-limiting illness, the interactions with health care matter most. As death nears, health care decisions can have a dramatic effect on how our patients and their families remember the last days. The issue of medical assistance in dying is far too complex for the scope of this article. But there is no question: When our patients are dying, they need our help more than ever.

Reflections on My First Five Years in Family Practice

Welcome to the Inaugural ACFP First Five Year Blog Post!

Our first post will be look back at my first year of practice after graduating residency. The first posting is Part 1 of three where I will focus on things I learned about myself and adapting to a new life of being the staff physician.

PART 1: Reflections on Being a Fresh Grad

There is a learning curve

I remember my first day in clinic after graduating like it was yesterday—I had a full schedule of patients and this was it—I’m a big boy now. Thinking about it now, there were many things I didn’t know that I had to quickly learn on the fly. I was always told there was a learning curve coming out of residency but I didn’t understand it until I experienced it for myself.

There is more than one way to practice medicine
As a learner, there was always only one way to practice that I knew of – the way of my preceptor. Now that I’m on my own, I see how people approach problems differently and this is ok. Medicine is an art and a science.

Textbook cases are not the norm.
As a resident, one of my preceptors had a favourite saying – after discussing cases she’d often sit back in her chair and say “Ah, the uncertainty of family medicine”. I don’t think I genuinely appreciated what that meant until after graduating. Now, I truly appreciate that most cases are a shade of gray.

Don’t be afraid to teach.
Teaching a student, or heaven forbid, a resident can be a bit daunting when you yourself are fresh out of residency. Don’t worry – despite your own fears you do have something to offer as you have more experience and time in the game. It’ll also keep your knowledge sharp and provide you with some outside perspective on your medical practice.

Medicine is always changing and the practitioner is always evolving; I suppose this is why it’s called the practice of medicine! What four things did you learn about yourself in your first year of practice? Please feel free to leave comments below!

Don’t forget to check back here next month for Part 2: Reflections on Practice Management.