Storylines of family medicine IV: perspectives on practice-lenses of appreciation.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IV: perspectives on practice-lenses of appreciation', authors address the following themes: 'Relational connections in the doctor-patient partnership', 'Feminism and family medicine', 'Positive family medicine', 'Mindful practice', 'The new, old ethics of family medicine', 'Public health, prevention and populations', 'Information mastery in family medicine' and 'Clinical courage.' May readers nurture their curiosity through these essays.

The Rural Integrated Community Clerkship: a vital stretch in the Alberta rural physician workforce pipeline.

Background: Longitudinal integrated clerkships are thought to operate synergistically with factors such as rural background and practice intent to determine medical graduates' practice types and locations-sometimes known as the pipeline effect. We examined the influence of the rural integrated community clerkship (ICC) at the University of Alberta on students choosing family medicine and rural practice. Methods: We completed a retrospective cohort analysis of graduates from 2009-2016. The cohort was cross-referenced by background, type of clerkship, practice type and practice location. We used χ2 analyses and risk ratios to measure the relative likelihood that ICC students would settle on rural practice and/or family medicine. Results: ICC participation had more influence than rural background on students' choice of rural and/or family practice, and both factors were synergistic. Rotation-based clerkship students were least likely to enter family medicine or rural practice. Conclusions: The ICC is a clerkship model that influences students to become rural and/or family physicians, regardless of their rural/urban origins. The ICC diverts rural-interested students into rural practice and protects rural-origin students from ending up in urban practice. Expanding ICC infrastructure, including sustaining the rural physician workforce, will benefit rural Alberta communities by increasing the numbers of UA graduates in rural practice.

Contexte: L'externat longitudinal intégré déterminerait, en synergie avec d'autres facteurs, notamment l'origine rurale et l'intention, le type de pratique et le lieu d'exercice des diplômés en médecine, un rapport appelé parfois « effet de pipeline ¼. Nous avons examiné dans quelle mesure l'externat communautaire intégré (ECI) en milieu rural à l'Université de l'Alberta incite les étudiants à choisir la médecine familiale ou l'exercice en milieu rural. Méthodes: Nous avons effectué une analyse de cohorte rétrospective des diplômés de 2009 à 2016. Les données sur la diplomation et celles sur l'origine, le type d'externat, la discipline et le lieu d'exercice ont été croisées. Nous avons utilisé le test du Chi-2 et le rapport de risques pour mesurer la probabilité relative que les étudiants qui ont fait l'ECI choisissent l'exercice en milieu rural et/ou la discipline de la médecine familiale. Résultats: Le fait d'avoir fait l'ECI a été un facteur plus déterminant que l'origine rurale quant au choix des étudiants d'exercer la médecine familiale ou de travailler en milieu rural, mais les deux facteurs étaient synergiques. Les étudiants ayant fait des stages rotatifs étaient les moins susceptibles d'opter pour la médecine familiale ou le milieu rural. Conclusions: L'ECC est un modèle d'externat qui incite les étudiants à se diriger vers la médecine familiale ou l'exercice en milieu rural, et ce, quelle que soit leur origine, rurale ou urbaine. Il amène ceux d'entre eux qui éprouvent déjà un intérêt pour l'exercice en milieu rural à concrétiser ce choix et ceux qui sont d'origine rurale à demeurer dans ce milieu pour y exercer leur profession. Le développement de l'infrastructure de l'ECC et le soutien que l'externat apporte à la main-d'œuvre médicale rurale profiteront aux collectivités rurales en dirigeant un plus grand nombre de diplômés de l'Université de l'Alberta vers l'exercice en milieu rural.

New insights on rural doctors' clinical courage in the context of the unfolding COVID-19 pandemic.

Introduction: Rural doctors typically work in low-resource settings and with limited professional support. They are sometimes pushed to the limits of their usual scope of practice to provide the medical care needed by their community. In a previous phenomenological study, we described the concept of clinical courage as underpinning rural doctors' work in this context. In this paper, we draw on rural doctors' experiences during the unfolding COVID pandemic to re-examine our understanding of the attributes of clinical courage. Methods: Semi-structured interviews were conducted with rural doctors from 11 countries who had experience preparing for or managing patients with COVID-19. Interviews were transcribed verbatim and coded using NVivo. A deductive thematic analysis was undertaken to identify common ideas and responses related to the features of clinical courage. Results: Thirteen interviews from rural doctors during the unfolding COVID-19 pandemic affirmed and enriched our understanding of the attributes of clinical courage, particularly the leadership role rural doctors can have within their communities. Conclusion: This study extended our understanding that rural doctors' experience of clinical courage is consistent amongst participants in many parts of the world, including developing countries.

Résumé Introduction: Les médecins ruraux travaillent généralement dans des environnements à faibles ressources et avec un soutien professionnel limité. Ils sont parfois poussés aux limites de leur champ d'action habituel pour fournir les soins médicaux dont leur communauté a besoin. Dans une étude phénoménologique précédente, et dans ce contexte, nous avons décrit le concept de courage clinique comme étant à la base du travail des médecins ruraux. Dans cet article, nous nous appuyons sur les expériences des médecins ruraux au cours de la pandémie de COVID pour réexaminer notre compréhension des attributs du courage clinique. Méthodes: Des entretiens semi-structurés ont été menés avec des médecins ruraux de 11 pays ayant une expérience de la préparation ou de la prise en charge de patients atteints de COVID-19. Les entretiens ont été transcrits mot à mot et codés à l'aide de NVivo. Une analyse thématique déductive a été entreprise pour identifier les idées et les réponses communes liées aux caractéristiques du courage clinique. Résultats: Treize entretiens avec des médecins ruraux, durant la pandémie de COVID-19, ont confirmé et enrichi notre compréhension des attributs du courage clinique, en particulier le rôle de leadership que les médecins ruraux peuvent jouer au sein de leurs communautés. Conclusion: Cette étude nous a permis de mieux comprendre que l'expérience des médecins ruraux en matière de courage clinique est la même pour tous les participants dans de nombreuses régions du monde, y compris dans les pays en développement. Mots-clés: Courage clinique, médecins ruraux, pandémie de COVID-19.

Developing conceptually sound items for a clinical courage questionnaire.

INTRODUCTION: Clinical courage can be described as a rural doctor's adaptability and willingness to undertake clinical work at the limits of their training and experience to meet the needs of their patients. This article describes the in-house development of survey items to include in a quantitative measure of clinical courage. METHODS: The questionnaire development involved two key concepts: a second-order latent factor model structure and a nominal group technique, used to develop consensus among the research team members. RESULTS: The steps taken to develop a sound clinical courage questionnaire are described in detail. The resulting initial questionnaire is presented, ready for testing with rural clinicians and refinement. CONCLUSION: This article outlines the psychometric process of questionnaire design and presents the resultant clinical courage questionnaire.

Exploring rural doctors' early experiences of coping with the emerging COVID-19 pandemic.

PURPOSE: To understand how rural doctors (physicians) responded to the emerging COVID-19 pandemic and their strategies for coping. METHODS: Early in the pandemic doctors (physicians) who practise rural and remote medicine were invited to participate through existing rural doctors' networks. Thirteen semi-structured interviews were conducted with rural doctors from 11 countries. Interviews were transcribed verbatim and coded using NVivo. A thematic analysis was used to identify common ideas and narratives. FINDINGS: Participants' accounts described highly adaptable and resourceful responses to address the crisis. Rapid changes to organizational and clinical practices were implemented, at a time of uncertainty, anxiety, and fear, and with limited information and resources. Strong relationships and commitment to their colleagues and communities were integral to shaping and sustaining these doctors' responses. We identified five common themes underpinning rural doctors' shared experiences: (1) caring for patients in a context of uncertainty, fear, and anxiety; (2) practical solutions through improvising and being resourceful; (3) gaining community trust and cooperation; (4) adapting to unrelenting pressures; and (5) reaffirming commitments. These themes are discussed in relation to the Lazarus and Folkman stress and coping model. CONCLUSIONS: With limited resources and support, these rural doctors' practical responses to the COVID-19 crisis underscore strong problem-focused coping strategies and shared commitments to their communities, patients, and colleagues. They drew support from sharing experiences with peers (emotion-focused coping) and finding positive meanings in their experiences (meaning-based coping). The psychosocial impact on rural doctors working at the limits of their adaptive resources is an ongoing concern.

The impact of interpersonal relationships on rural doctors' clinical courage.

INTRODUCTION: Clinical courage occurs when rural doctors push themselves to the limits of their scope of practice to provide the medical care needed by patients in their community. This mental strength to venture, persevere and act out of concern for one's patient, despite a lack of formally recognised expertise, becomes necessary for doctors who work in relative professional isolation. Previous research by the authors suggested that the clinical courage of rural doctors relies on the relationships around them. This article explores in more depth how relationships with others can impact on clinical courage. METHODS: At an international rural medicine conference in 2017, doctors who practised rural/remote medicine were invited to participate in the study. Twenty-seven semistructured interviews were conducted exploring experiences of clinical courage. Initial analysis of the material, using a hermeneutic phenomenological frame, sought to understand the meaning of clinical courage. In the original analysis, an emic question arose: 'How do interpersonal relationships impact on clinical courage'. The material was re-analysed to explore this question, using Wenger's community of practice as a theoretical framework. RESULTS: This study found that clinical courage was affected by the relationships rural doctors had with their communities and patients, with each other, with the local members of their healthcare team and with other colleagues and health leaders outside their immediate community of practice. CONCLUSION: As a collective, rural doctors can learn, use and strengthen clinical courage and support its development in new members of the discipline. Relationships with rural communities, rural patients and urban colleagues can support the clinical courage of rural doctors. When detractors challenge the value of clinical courage, it requires individual rural doctors and their community of practice to champion rural doctors' way of working.

Crisis and continuity: Rural health care students respond to the COVID-19 outbreak.

The COVID-19 outbreak in Winter (2020) has caused widespread disruption for health sciences students undergoing clinical placements-vital periods of experiential learning that cannot be substituted with distance alternatives. For students placed in rural areas, already coping with isolation, precarious supply chains and shortages of essential personnel, the effects of the COVID-19 outbreak may have far-reaching implications for psychosocial wellness, self-efficacy and clinical judgment. Four nursing and eight medical students (n = 12) supplied photographs and commentary documenting the experience of withdrawing suddenly from clinical sites in rural Alberta. Collaborative, thematic analysis revealed continuities between pre- and post-outbreak life, both for the students and their rural hosts. Social determinants of health such as seclusion, environmental hazards, and health-seeking behaviors carried over and compounded the effects of the outbreak on the placement communities and clinical sites. Other continuities included the reliance on technology for clinical and social connectivity, and capitalizing on natural settings to cope with isolation and confinement. Prolonged liminality, lack of closure, and the loss of team identity were the greatest stressors brought on by the suspension of clinical activities. However, the participants felt well equipped to deal with these circumstances through the resilience, adaptability, and community ethos acquired during their placements.

Exploration of rural physicians' lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): an international phenomenological study.

OBJECTIVES: Rural doctors describe consistent pressure to provide extended care beyond the limits of their formal training in order to meet the needs of the patients and communities they serve. This study explored the lived experience of rural doctors when they practise outside their usual scope of practice to provide medical care for people who would otherwise not have access to essential clinical services. DESIGN: A hermeneutic phenomenological study. SETTING: An international rural medicine conference. PARTICIPANTS: All doctors attending the conference who practised medicine in rural/remote areas in a predominantly English-speaking community were eligible to participate; 27 doctors were recruited. INTERVENTIONS: Semi-structured interviews were conducted. The transcripts were initially read and analysed by individual researchers before they were read aloud to the group to explore meanings more fully. Two researchers then reviewed the transcripts to develop the results section which was then rechecked by the broader group. PRIMARY OUTCOME MEASURE: An understanding of the lived experiences of clinical courage. RESULTS: Participants provided in-depth descriptions of experiences we have termed clinical courage. This phenomenon included the following features: Standing up to serve anybody and everybody in the community; Accepting uncertainty and persistently seeking to prepare; Deliberately understanding and marshalling resources in the context; Humbly seeking to know one's own limits; Clearing the cognitive hurdle when something needs to be done for your patient; Collegial support to stand up again. CONCLUSION: This study elucidated six features of the phenomenon of clinical courage through the narratives of the lived experience of rural generalist doctors.

Provision of consumer health information in Alberta's Rural Public Libraries.

BACKGROUND: Access to health services is a major challenge in many rural communities within Canada. Rural public libraries can serve as centres for health resources. OBJECTIVE: The aim of this exploratory study was to analyse the manner in which Alberta's rural libraries provide health information to their patrons. METHODS: A questionnaire including closed ended and open ended questions was sent to the 285 rural libraries across the Canadian province of Alberta. Descriptive statistics and thematic analysis techniques were used for the data analysis. RESULTS: The findings indicate that in three quarters of Alberta's rural libraries, about 10% of requests for assistance were related to health issues. The provision of health information in these libraries is hampered by the lack of Internet, private space for reference interviews, and staff and volunteer training. Library staff members were inexperienced in conducting reference transactions and reported lacking confidence in meeting patrons' needs and ethical standards. DISCUSSION: Addressing these challenges will require the recruitment of more qualified librarians in rural library systems, possibly through incentive measures, and a comprehensive education and training programme for both staff and volunteers combined with the necessary resource support for the rural libraries. CONCLUSION: When human and material resources are adequate, rural libraries can contribute to improving the health literacy of their communities.

A review of methods to assess the economic impact of distributed medical education (DME) in Canada.

BACKGROUND: Canadian distributed medical education (DME) increased substantially in the last decade, resulting in positive economic impacts to local communities. A reliable and simple method to estimate economic contributions is essential to provide managers with information on the extent of these impacts. This review paper fills a gap in the literature by answering the question: What are the most applicable quantitative methods to assess the economic impact of Canadian DME programs? METHODS: The literature is reviewed to identify economic assessment methods. These are evaluated and compared based on the benefits, challenges, data needs, outputs and potential for use in the DME context. RESULTS: We identified five economic impact methods used in similar contexts. Two of these methods have the potential for Canadian DME programs: the Canadian Input-Output (I-O) model and the Simplified American Council on Education (ACE) method. CONCLUSION: Choice of a method is contingent on the ability to measure the salient economic impacts, and provide an output that facilitates sustainable decision making. This paper thus fills a gap by identifying methods applicable to DME. These methods will assist stakeholders to calculate economic impacts, resulting in both the advancement and sustainability of these programs over short-and long-term time frames.

What are the features of targeted or system-wide initiatives that affect diversity in health professions trainees? A BEME systematic review: BEME Guide No. 50.

BACKGROUND/PURPOSE: There is interest to increase diversity among health professions trainees. This study aims to determine the features/effects of interventions to promote recruitment/admission of under-represented minority (URM) students to health professions programs. METHODOLOGY: This registered BEME review applied systematic methods to: title/full-text inclusion review, data extraction, and quality assessment (QA). Included studies reported outcomes for interventions designed to increase diversity of health professions education (HPE) programs' recruitment and admissions. RESULTS: Of 7225 studies identified 86 met inclusion criteria. Interventions addressed: admissions (34%), enrichment (19%), outreach (15%), curriculum (3%), and mixed (29%). They were mostly single center (76%), from the United States (81%), in medicine (45%) or dentistry (22%). URM definition was stated in only 24%. The dimension most commonly considered was ethnicity/race (88%). The majority of studies (81%) found positive effects. Heterogeneity precluded meta-analysis. Qualitative analysis identified key features: admissions studies points systems and altered weightings; enrichment studies highlighted academic, application and exam preparation, and workplace exposure. DISCUSSION/CONCLUSIONS: Several intervention types may increase diversity. Limited applicant pools were a rate-limiting feature, suggesting efforts earlier in the continuum are needed to broaden applicant pools. There is a need to examine underlying cultural and external pressures that limit programs' acceptance of initiatives to increase diversity.

Nursing Students Achieving Community Health Competencies through Undergraduate Clinical Experiences: A Gap Analysis.

In Canada, it is widely believed that nursing practice and health care will move from acute care into the community. At the same time, increasing numbers of nursing students are engaged in non-traditional clinical experiences for their community health rotation. These clinical experiences occur at agencies not organizationally affiliated with the health care system and typically do not employ registered nurses (RNs). What has yet to be established is the degree to which nursing students are actually being prepared for community health nursing roles through their community health clinical rotations. In this paper we report the findings of a mixed method study that explored the gap between desired and observed levels of competence in community health of senior nursing students and new graduates. The gap was quantified and then the nature of the gap further explored through focus groups.

Disconnects in pedagogy and practice in community health nursing clinical experiences: Qualitative findings of a mixed method study.

BACKGROUND: Many baccalaureate schools of nursing are using non-traditional placements for undergraduate community health clinical rotations. These placements occur at agencies not organizationally affiliated with the health care system and they typically do not employ registered nurses (RNs). OBJECTIVES AND DESIGN: In this paper, we describe the qualitative findings of a mixed method study that explored these gaps as they relate to pre-registration nursing students' preparation for community health roles. RESULTS: While non-traditional community health placements offer unique opportunities for learning through carefully crafted service learning pedagogy, these placements also present challenges for student preparation for practice in community health roles. The theory-practice gap and the gap between the expected and actual performance of new graduates are accentuated through the use of non-traditional community clinical experiences. These gaps are not necessarily due to poor pedagogy, but rather due to the perceptions and values of the stakeholders involved: nursing students, community health nursing faculty, and community health nurses. CONCLUSIONS: New ways must be developed between academe and community health practice areas to provide students with opportunities to develop competence for practice.

Competence and competency-based nursing education: finding our way through the issues.

The language of competence is widely utilized in both the regulation of nursing practice and curricular design in nursing education. The notion of competence defines what it means to be a professional, although it is not the only way of describing nursing practice. Unfortunately, there is much confusion about the concepts of competence, competency, and competency-based education. As well, the notion of competence, despite its global popularity, has flaws. In this paper we will disentangle these terms and critique the use of competence frameworks in nursing education.

Twelve tips for designing and running longitudinal integrated clerkships.

Longitudinal integrated clerkships (LICs) involve learners spending an extended time in a clinical setting (or a variety of interlinked clinical settings) where their clinical learning opportunities are interwoven through continuities of patient contact and care, continuities of assessment and supervision, and continuities of clinical and cultural learning. Our twelve tips are grounded in the lived experiences of designing, implementing, maintaining, and evaluating LICs, and in the extant literature on LICs. We consider: general issues (anticipated benefits and challenges associated with starting and running an LIC); logistical issues (how long each longitudinal experience should last, where it will take place, the number of learners who can be accommodated); and integration issues (how the LIC interfaces with the rest of the program, and the need for evaluation that aligns with the dynamics of the LIC model). Although this paper is primarily aimed at those who are considering setting up an LIC in their own institutions or who are already running an LIC we also offer our recommendations as a reflection on the broader dynamics of medical education and on the priorities and issues we all face in designing and running educational programs.

Perceived preparedness for family practice: does rural background matter?

INTRODUCTION: Rural background and the ability to adjust to rural practice are strong predictors of recruitment and retention of rural physicians. The degree to which rural background and being prepared for practice interrelate may provide insight into efforts aimed at increasing the supply of rural physicians. The purpose of this study was to examine the association between family medicine graduates' rural or urban background and their self-reported preparedness for practice. METHODS: This was a retrospective, cross-sectional survey of family medicine graduates who completed the 2-year family medicine residency program at the University of Alberta or University of Calgary from 2001 to 2005. Self-rated preparedness was examined on a 4-point Likert scale for 18 elements of clinical family practice, 8 interdisciplinary issues, 10 practice management issues and 8 nonclinical aspects of family practice. Rural background was defined as having been brought up mainly in a rural community (population < 25 000), and urban background was defined as having been brought up mainly in an urban community (population ≥ 25 000). RESULTS: A significantly greater proportion of rural-than urban-background graduates felt prepared for 3 nonclinical aspects of rural practice: time demands of rural practice (95.0% v. 79.3%, p = 0.03), understanding rural culture (92.5% v. 70.2%, p = 0.005) and small-community living (92.5% v. 70.2%, p = 0.003). CONCLUSION: Rural background was associated with physicians feeling prepared for the nonclinical and cultural aspects of rural family practice, which suggests that focused rural exposure facilitates an understanding of rural culture. Urban-background physicians were reportedly less prepared for the nonclinical aspects of rural practice. Increased exposure of urban-background residents to the cultural aspects of rural practice may improve recruitment and retention of rural family physicians.

Student perceptions of assessment and feedback in longitudinal integrated clerkships.

OBJECTIVES: This study was conducted to elucidate how the learning environment and the student-preceptor relationship influence student experiences of being assessed and receiving feedback on performance. Thus, we examined how long-term clinical clerkship placements influence students' experiences of and views about assessment and feedback. METHODS: We took a constructivist grounded approach, using authentic assessment and communities of practice as sensitising concepts. We recruited and interviewed 13 students studying in longitudinal integrated clerkships across two medical schools and six settings, using a semi-structured interview framework. We used an iterative coding process to code the data and arrive at a coding framework and themes. RESULTS: Students valued the unstructured assessment and informal feedback that arose from clinical supervision, and the sense of progress derived from their increasing responsibility for patients and acceptance into the health care community. Three themes emerged from the data. Firstly, students characterised their assessment and feedback as integrated, developmental and longitudinal. They reported authenticity in the monitoring and feedback that arose from the day-to-day delivery of patient care with their preceptors. Secondly, students described supportive and caring relationships and a sense of safety. These enabled them to reflect on their strengths and weaknesses and to interpret critical feedback as supportive. Students developed similar relationships across the health care team. Thirdly, the long-term placement provided for multiple indicators of progress for students. Patient outcomes were perceived as representing direct feedback about students' development as doctors. Taking increasing responsibility for patients over time is an indicator to students of their increasing competence and contributes to the developing of a doctor identity. CONCLUSIONS: Clerkship students studying for extended periods in one environment with one preceptor perceive assessment and feedback as authentic because they are embedded in daily patient care, useful because they are developmental and longitudinal, and constructive because they occur in the context of a supportive learning environment and relationship.