Perceptions of family medicine in Canada through the eyes of learners.

OBJECTIVE: To examine the perceptions of family medicine (FM) residents about their chosen specialty and how they perceive that patients, other specialists, and the government value FM. DESIGN: Self-report data from the Family Medicine Longitudinal Survey collected from 2014 (time 1 [T1]) to 2016 (time 2 [T2]). SETTING: Canada. PARTICIPANTS: Family medicine residents from 16 out of the 17 FM residency programs. MAIN OUTCOME MEASURES: Responses to statements in the survey were evaluated using a 5-point Likert scale (from strongly disagree to strongly agree). Data were analyzed in 2 ways: cross sectionally (participation in either T1 or T2), and longitudinally (participation in both T1 and T2). RESULTS: For both the cross-sectional cohorts (T1, n = 916; T2, n = 785) and the repeated-measures cohort (n = 420), most residents responded positively to feeling proud of becoming a family physician, with little change from entrance to exit. For both cohorts, a higher proportion of residents at the end of training reported that other medical specialists value the contributions of family physicians (P < .001); however, fewer believed that the government perceived FM as essential to the health care system (P < .001). CONCLUSION: Most participating Canadian FM residents feel proud to become family physicians. This feeling may come from the perceptions of others who are believed to value FM, including other specialists. Measuring attitudinal perceptions offers a window to discover how FM is viewed and can offer a way to measure the effect of strategies implemented to advance the discipline of FM.

Future practice of comprehensive care: Practice intentions of exiting family medicine residents in Canada.

OBJECTIVE: To describe exiting family medicine (FM) residents' reported practice intentions after completing a Triple C Competency-based Curriculum. DESIGN: The surveys were intended to capture residents' perceptions of FM, their perceptions of their competency-based training, and their intentions to practise FM. Entry (T1) and exit (T2) self-reported survey results were compared considering the influence of the curriculum change. Unmatched aggregate-level data were reviewed. The T1 survey was administered in the summer of 2012 and the T2 survey was administered in the spring of 2014. SETTING: Six Canadian FM residency programs across 4 provinces in Canada (Alberta, Saskatchewan, Ontario, and Quebec). PARTICIPANTS: Overall, 341 entering FM residents in 2012 responded to the T1 survey and 325 exiting FM residents completing their residency programs in spring 2014 responded to the T2 survey. MAIN OUTCOME MEASURES: Self-reported data on FM residents' future practice intentions related to comprehensive care, providing care across clinical domains and settings, and providing comprehensive care individually or in teams. RESULTS: A total of 341 (71.3%) residents responded to the T1 survey and a total of 325 (71.4%) residents responded to the T2 survey. Of these, 78.7% responded that they intended to provide comprehensive FM in multiple clinical settings in their future practices, with 70.8% indicating a comprehensive care practice with a special interest and 36.6% intending to provide care in a focused practice. Overall, 92.9% reported that they intended to work in group practice environments. Ninety percent reported they intended to work in interprofessional team practices. CONCLUSION: While an upward trend toward the practice of comprehensive care was demonstrated, findings also showed an increased trend toward providing care in focused practices. Further research is needed to better determine how FM residents understand the definition of comprehensive FM and its practice models. The survey provides an opportunity to explore questions related to practice intentions that could be helpful in work force planning. As the first study to compare entry and exit data from learners who have been exposed to a Triple C competency-based approach, this survey provides important baseline data for use by many.

Family medicine education in rural communities as a health service intervention supporting recruitment and retention of physicians: Advancing Rural Family Medicine: The Canadian Collaborative Taskforce.

OBJECTIVE: To develop a pan-Canadian rural education road map to advance the recruitment and retention of family physicians in rural, remote, and isolated regions of Canada in order to improve access and health care outcomes for these populations. COMPOSITION OF THE TASK FORCE: Members of the task force were chosen from key stakeholder groups including educators, practitioners, the College of Family Physicians of Canada education committee chairs, deans, chairs of family medicine, experts in rural education, and key decision makers. The task force members were purposefully selected to represent a mix of key perspectives needed to ensure the work produced was rigorous and of high quality. Observers from the Canadian Medical Association and Health Canada's Council on Health Workforce, and representatives from the Royal College of Physicians and Surgeons of Canada, were also invited to provide their perspectives and to encourage and coordinate multiorganization action. METHODS: The task force commissioned a focused literature review of the peer-reviewed and gray literature to examine the status of rural medical education, training, and practice in relation to the health needs of rural and remote communities in Canada, and also completed an environmental scan. REPORT: The environmental scan included interviews with more than 100 policy makers, government representatives, providers, educators, learners, and community leaders; 17 interviews with practising rural physicians; and 2 surveys administered to all 17 faculties of medicine. The gaps identified from the focused literature review and the results of the environmental scan will be used to develop the task force's recommendations for action, highlighting the role of key partners in implementation and needed action. CONCLUSION: The work of the task force provides an opportunity to bring the various partners together in a coordinated way. By understanding who is responsible and the actions each stakeholder needs to take to make the recommendations a reality, the task force can lay the groundwork for developing a coordinated, comprehensive health human resource strategy that considers the integral role of medical education as a health system intervention.

Extended family medicine training: Measuring training flows at a time of substantial pedagogic change.

OBJECTIVE: To examine trends in family medicine training at a time when substantial pedagogic change is under way, focusing on factors that relate to extended family medicine training. DESIGN: Aggregate-level secondary data analysis based on the Canadian Post-MD Education Registry. SETTING: Canada. PARTICIPANTS: All Canadian citizens and permanent residents who were registered in postgraduate family medicine training programs within Canadian faculties of medicine from 1995 to 2013. MAIN OUTCOME MEASURES: Number and proportion of family medicine residents exiting 2-year and extended (third-year and above) family medicine training programs, as well as the types and numbers of extended training programs offered in 2015. RESULTS: The proportion of family medicine trainees pursuing extended training almost doubled during the study period, going from 10.9% in 1995 to 21.1% in 2013. Men and Canadian medical graduates were more likely to take extended family medicine training. Among the 5 most recent family medicine exit cohorts (from 2009 to 2013), 25.9% of men completed extended training programs compared with 18.3% of women, and 23.1% of Canadian medical graduates completed extended training compared with 13.6% of international medical graduates. Family medicine programs vary substantially with respect to the proportion of their trainees who undertake extended training, ranging from a low of 12.3% to a high of 35.1% among trainees exiting from 2011 to 2013. CONCLUSION: New initiatives, such as the Triple C Competency-based Curriculum, CanMEDS-Family Medicine, and Certificates of Added Competence, have emerged as part of family medicine education and credentialing. In acknowledgment of the potential effect of these initiatives, it is important that future research examine how pedagogic change and, in particular, extended training shapes the care family physicians offer their patients. As part of that research it will be important to measure the breadth and uptake of extended family medicine training programs.

Giving curriculum planners an edge: using entrance surveys to design family medicine education.

OBJECTIVE: To pilot a survey of family medicine residents entering residency, describing their exposure to family medicine and their perspectives related to their future intentions to practise family medicine, in order to inform curriculum planners; and to test the methodology, feasibility, and utility of delivering a longitudinal survey to multiple residency programs. DESIGN: Pilot study using surveys. SETTING: Five Canadian residency programs. PARTICIPANTS: A total of 454 first-year family medicine residents were surveyed. MAIN OUTCOME MEASURES: Residents' previous exposure to family medicine, perspectives on family medicine, and future practice intentions. RESULTS: Overall, 70% of first-year residents surveyed responded (n = 317). Although only 5 residency programs participated, respondents included graduates from each of the medical schools in Canada, as well as international medical graduates. Among respondents, 92% felt positive or strongly positive about their choice to be family physicians. Most (73%) indicated they had strong or very strong exposure to family medicine in medical school, yet more than 40% had no or minimal exposure to key clinical domains of family medicine like palliative care, home care, and care of underserved groups. Similar responses were found about residents' lack of intention to practise in these domains. CONCLUSION: Exposure to clinical domains in family medicine could influence future practice intentions. Surveys at entrance to residency can help medical school and family medicine residency planners consider important learning experiences to include in training.

Family practice registered nurses: The time has come.

OBJECTIVE: To provide a picture of the unique role and competencies of family practice registered nurses (FP-RNs). DESIGN: Case-study approach using interviews and focus groups. SETTING: Ontario. PARTICIPANTS: Seven FP-RNs identified as exemplary by family medicine and nursing peers. METHODS: An e-mail was sent to 9200 health care providers from nursing and family medicine, asking them to identify names of exemplary family practice nurses. Using a purposive sampling methodology, 7 exemplary FP-RNs were selected, taking into consideration the number of years in practice as a nurse, location of practice, length of practice as an FP-RN, and type of family practice. Individual interviews were held, and focus groups were organized with colleagues. Narratives were analyzed iteratively by the project team. MAIN FINDINGS: Four main themes emerged: The first theme relates to the relationship-centred approach to care delivered by FP-RNs, founded upon trust. The second theme highlights the FP-RN's unique skills in balancing the priorities of patients, colleagues, and the clinic as a whole. The third theme capitalizes on the nurses' commitment to advancing their learning to enhance their abilities to be FP-RNs. The fourth theme illuminates the perspectives shared by FP-RNs that family practice is uniquely different from acute care in the manner in which care is delivered. We draw attention to the approach and role of FP-RNs in Ontario. The 4 themes that emerged have striking similarities to stories shared by family physicians and to the evolutionary development of the discipline of family medicine. CONCLUSION: We believe the findings from this paper can help shape the role of the FP-RN within clinical practice and that they will propagate discussion among nursing educators to consider the necessary educational preparation required to develop the FP-RNs needed in this country.

Conceptualization of Competency-Based Medical Education Terminology in Family Medicine Postgraduate Medical Education and Continuing Professional Development: A Scoping Review.

PURPOSE: To examine the extent, range, and nature of how competency-based medical education (CBME) implementation terminology is used (i.e., the conceptualization of CBME-related terms) within the family medicine postgraduate medical education (PGME) and continuing professional development (CPD) literature. METHOD: This scoping review's methodology was based on Arksey and O'Malley's framework and subsequent recommendations by Tricco and colleagues. The authors searched 5 databases and the gray literature for U.S. and Canadian publications between January 2000 and April 2017. Full-text English-language articles on CBME implementation that focused exclusively on family medicine PGME and/or CPD programs were eligible for inclusion. A standardized data extraction form was used to collect article demographic data and coding concepts data. Data analysis used mixed methods, including quantitative frequency analysis and qualitative thematic analysis. RESULTS: Of 470 unique articles identified, 80 (17%) met the inclusion criteria and were selected for inclusion in the review. Only 12 (15%) of the 80 articles provided a referenced definition of the coding concepts (i.e., referred to an article/organization as the definition's source), resulting in 19 highly variable-and 12 unique- referenced definitions of key terms used in CBME implementation (competence, competency, competency-based medical education). Thematic analysis of the referenced definitions identified 15 dominant themes, among which the most common were (1) a multidimensional and dynamic concept that encompasses a variety of skill components and (2) being able to use communication, knowledge, technical skills, clinical reasoning, judgment, emotions, attitudes, personal values, and reflection in practice. CONCLUSIONS: The construction and dissemination of shared definitions is essential to CBME's successful implementation. The low number of referenced definitions and lack of consensus on such definitions suggest more attention needs to be paid to conceptual rigor. The authors recommend those involved in family medicine education work with colleagues across medical specialties to develop a common taxonomy.

Student leadership in interprofessional education: benefits, challenges and implications for educators, researchers and policymakers.

Context Interprofessional collaboration is gaining increasing prominence as a team-based approach to health care delivery that synergistically maximises the strengths of each health professional to enhance patient care, decrease medical errors and optimise efficiency. The often neglected role that student leaders have in preparing their peers, as the health professionals of the future, for collaboration in health care should not be overlooked. Objective This paper offers the foundational arguments supporting the integral role that student leadership in interprofessional education (IPE) can play and its comparative advantages. Methods Evidence from previous literature and the National Health Science Students' Association in Canada was reviewed and a questionnaire on student-initiated IPE was administered among Canada's top student leaders in this area. Results Student leadership is essential to the success of IPE because it enhances students' willingness to collaborate and facilitates the longterm sustainability of IPE efforts. Student-initiated IPE, a subset of student leadership, is particularly important to achieving the aforementioned goals and offers a number of benefits, comparative advantages and associated challenges. Conclusions Successful student leadership in IPE will yield significant benefits for everyone in the years to come. However, it requires the support of educators, researchers and policymakers in fostering an enabling environment that will facilitate the efforts and contributions of student leaders.

Health advocacy: bringing clarity to educators through the voices of physician health advocates.

BACKGROUND: Although advocacy is a value that is acknowledged among care providers, the definition of advocacy and the competencies associated with it vary among those who teach it. METHOD: Grounded theory analysis was used on case studies of eight physicians identified as being responsive to community needs. RESULTS: Community-responsive physicians were found to engage in health advocacy by working with, or on behalf of, their patients/communities through being either (a) informants-providing information to those who can enact change, or (b) change agents-initiating, mobilizing, and organizing ways to systematically modify policies or procedures that negatively effect patients/communities. Issues of health advocacy as they relate to the determinants of health and health promotion are highlighted. CONCLUSIONS: This article provides an enhanced understanding of health advocacy and proposes an operational definition of health advocacy that may allow for an enhanced method of teaching health advocacy to learners.

Educating for advocacy: exploring the source and substance of community-responsive physicians.

PURPOSE: Physicians are called to be community responsive. But with few existing operational definitions, how can it be taught? The nature, inclination, and impact of community-responsive physicians were studied to address this educational fissure. METHOD: Case studies on eight community-responsive physicians were conducted. Data were qualitatively analyzed using NVivo software. RESULTS: One way physicians were community responsive was through advocacy. Three themes arose: (1) having knowledge of difference, social determinants of health, and the power and privilege of physicians; (2) being influenced by role models and exposure to marginalized groups; and (3) motivation to do the right thing, give back, make a difference, and be intellectually challenged. CONCLUSIONS: Educational strategies to advance the teaching of physicians to be community-responsive advocates are highlighted.

Family physicians and home care agencies--valuing each other's roles in primary care.

BACKGROUND: In this era of primary-care reform, family physicians are being encouraged to work in teams with allied health professionals and community resources, including home care services, to ensure optimum care is provided to their patients. OBJECTIVE: To learn about the experiences of physicians working with home care services as provided by the Toronto Community Care Access Centre. METHODS: In early 2001, the Toronto Community Care Access Centre (CCAC) hosted focus groups designed to understand physicians' knowledge of and experiences with the home care services provided by our organization. Data analysis was conducted using grounded theory methodology. RESULTS: Three themes emerged: (1) family physicians have a limited understanding of home care services; (2) family physicians felt there were inconsistencies related to service provision by CCAC staff; and (3) family physicians felt that their role may not be valued when caring for mutual clients with CCACs. OUTCOMES: Better educational interventions informing physicians on CCAC services and improved organizational practices by CCACs may aid in improving the connection between family physicians and CCACs.

Factors in implementing interprofessional education and collaborative practice initiatives: findings from key informant interviews.

Health Canada (the federal government department in Canada responsible for health issues) commissioned a research team to conduct an environmental scan and research report in order to understand interprofessional education and collaborative patient-centred practice (IECPCP). This paper presents the findings from semi-structured telephone interviews with key informants conducted as part of the environmental scan. Grounded theory analysis was employed in order to identify factors associated with interprofessional education and collaborative practice initiatives. These factors were grouped according the following themes: lack of consensus regarding terminology; the need for both champions and external support; sensitization to the effects of professional culture, and logistics of implementation. Findings are discussed related to the literature and to the other papers included in this supplement to the Journal of Interprofessional Care.