In the Canadian health care system, Family Practice Anesthesia (FPA) is a specialized area of medical practice dedicated to providing a wide range of safe and competent anesthesia services to patients of all ages, especially those in smaller and rural communities. A Certificate of Added Competence in FPA may be awarded to family medicine resident trainees or practitioners who complete an Enhanced Skills program in FPA, which is typically a year-long course of study in collaboration with an anesthesiology department that prepares trainees to deliver general, neuraxial, and regional anesthesia, mostly for uncomplicated and especially emergent procedures. Trainees also learn to identify when procedures may be more appropriately performed at other institutions.1,2,3 The Family Practice Anesthetist model aims to increase access to anesthesia care while balancing care and safety standards. This attempted solution to the shortage of anesthesia professionals contrasts with the US system, in which nurse anesthetists supplement physician anesthesiologists.
While most anesthesia care in Canada is provided by physicians who have completed residencies in anesthesiology and passed a national examination, the Family Practice Anesthetist model allows FPAs to fill gaps in providing timely anesthesia care when challenged by geographic and socioeconomic factors.3 However, criticism of this care model highlights the lack of standardized training and evaluation, with medical organizations such as the Society of Rural Physicians of Canada, the College of Family Physicians of Canada, and the Canadian Anesthesiologists Society expressing concern over the efficacy of FPA training programs in improving care in rural Canada.4 Those living in rural and isolated regions may include Indigenous Peoples, who have higher rates of post-surgical death and adverse events than the general population according to available evidence.5
Community-based services, rather than purely regional services, are essential to Canada’s health care system, promoting health equity by enabling sparsely distributed populations to access care locally, especially if travel distances or conditions preclude transit to larger towns or cities.4 In small community hospitals, the provision of anesthesia may depend completely on FPAs. In Ontario in the early 2000s, 39% of the 128 hospitals that provided anesthesia services relied entirely on FPAs, and 59% of hospitals employed at least one FPA.6 A prior study of the isolated Inuvik region found that the most common procedures performed by family medicine practitioners included endoscopic and obstetric/gynecologic procedures, as well as general surgery cases. Cesarean sections, appendectomies, and cholecystectomies were among the more common procedures, which helps reduce the surgical load on other physicians.7
Importantly, many of these hospitals reported shortages of FPAs, with future shortages anticipated.6 Research is ongoing to capture the number of FPAs, which Canadian databases have failed to consistently do.3 As of 2018, the number of FPAs was likely between 350-550 providers; in contrast, the number of anesthesia specialists was likely between 2,600-3,000 doctors.3
Going forward, Canadian family medicine societies should prioritize ensuring that training for FPAs remains robust and that trainees are motivated to pursue this essential line of work so that the Family Practice Anesthetist model can continue and improve.4 Currently, there is no core curriculum for training and evaluating FPAs, though a “Red Book” has established standards for accreditation.1,2,4 Though most FPAs feel that their training prepared them to competently provide general anesthesia, regional anesthesia, and epidural services, those with a year or more of training felt that they were more immediately prepared to meet the demands of practice and also receive support from local colleagues. Increasing the number of available training positions, improving coordination and standardization of training, and recognizing the need to support FPAs is essential to sustaining this small but important part of Canada’s physician workforce.6
References
- Priority Topics and Key Features for the Assessment of Competence in Family Practice Anesthesia. The College of Family Physicians of Canada. Published April 2017. https://www.cfpc.ca/CFPC/media/Resources/Education/FPA_KF_Final_ENG.pdf
- Certificates of Added Competence in Family Medicine. The College of Family Physicians of Canada. https://www.cfpc.ca/en/education-professional-development/examinations-and-certification/certificates-of-added-competence-in-family-medicin
- Simkin S, Orser BA, Wilson CR, Bourgeault IL. The anesthesia workforce in Canada: a methodology to identify physician anesthesia providers using health administrative data. Human Resources for Health. 2023;21(1):34. doi:10.1186/s12960-023-00820-w
- Witt A, Iglesias S, Ashbury T. Evaluation of Canadian family practice anesthesia training programs: can the Resident Logbook help? Canadian Journal Anesthesia. 2012;59(10):968-973. doi:10.1007/s12630-012-9759-8
- McVicar JA, Poon A, Caron NR, et al. Postoperative outcomes for Indigenous Peoples in Canada: a systematic review. Canadian Medical Association Journal. 2021;193(20):E713-E722. doi:10.1503/cmaj.191682
- Brown G, Godwin M, Seguin R, Ashbury EL. Family medicine anesthesia: sustaining an essential service. Canadian Family Physician. 2005;51:538-539.
- Falk R, Topstad D. Surgery in the western Canadian Arctic: The relative impact of family physicians with enhanced surgical skills working collaboratively with specialist surgeons. Canadian Journal of Rural Medicine. 2023;28(2):66-72. doi:10.4103/cjrm.cjrm_44_22
