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.

Family medicine graduates' perceptions of intimidation, harassment, and discrimination during residency training.

BACKGROUND: Despite there being considerable literature documenting learner distress and perceptions of mistreatment in medical education settings, these concerns have not been explored in-depth in Canadian family medicine residency programs. The purpose of the study was to examine intimidation, harassment and/or discrimination (IHD) as reported by Alberta family medicine graduates during their two-year residency program. METHODS: A retrospective questionnaire survey was conducted of all (n = 377) family medicine graduates from the University of Alberta and University of Calgary who completed residency training during 2001-2005. The frequency, type, source, and perceived basis of IHD were examined by gender, age, and Canadian vs international medical graduate. Descriptive data analysis (frequency, crosstabs), Chi-square, Fisher's Exact test, analysis of variance, and logistic regression were used as appropriate. RESULTS: Of 377 graduates, 242 (64.2%) responded to the survey, with 44.7% reporting they had experienced IHD while a resident. The most frequent type of IHD experienced was in the form of inappropriate verbal comments (94.3%), followed by work as punishment (27.6%). The main sources of IHD were specialist physicians (77.1%), hospital nurses (54.3%), specialty residents (45.7%), and patients (35.2%). The primary basis for IHD was perceived to be gender (26.7%), followed by ethnicity (16.2%), and culture (9.5%). A significantly greater proportion of males (38.6%) than females (20.0%) experienced IHD in the form of work as punishment. While a similar proportion of Canadian (46.1%) and international medical graduates (IMGs) (41.0%) experienced IHD, a significantly greater proportion of IMGs perceived ethnicity, culture, or language to be the basis of IHD. CONCLUSIONS: Perceptions of IHD are prevalent among family medicine graduates. Residency programs should explicitly recognize and robustly address all IHD concerns.

Assessing clinical communication skills in physicians: are the skills context specific or generalizable.

BACKGROUND: Communication skills are essential for physicians to practice Medicine. Evidence for the validity and domain specificity of communication skills in physicians is equivocal and requires further research. This research was conducted to adduce evidence for content and context specificity of communication skills and to assess the usefulness of a generic instrument for assessing communication skills in International Medical Graduates (IMGs). METHODS: A psychometric design was used for identifying the reliability and validity of the communication skills instruments used for high-stakes exams for IMG's. Data were collected from 39 IMGs (19 men--48.7%; 20 women--51.3%; Mean age = 41 years) assessed at 14 station OSCE and subsequently in supervised clinical practice with several instruments (patient surveys; ITERs; Mini-CEX). RESULTS: All the instruments had adequate reliability (Cronbach's alpha: .54 - .96). There were significant correlations (r range: 0.37 - 0.70, p < .05) of communication skills assessed by examiner with standardized patients, and of mini-CEX with patient surveys, and ITERs. The intra-item reliability across all cases for the 13 items was low (Cronbach's alpha: .20 - .56). The correlations of communication skills within method (e.g., OSCE or clinical practice) were significant but were non-significant between methods (e.g., OSCE and clinical practice). CONCLUSION: The results provide evidence of context specificity of communication skills, as well as convergent and criterion-related validity of communication skills. Both in OSCEs and clinical practice, communication checklists need to be case specific, designed for content validity.

Social rates of return to investment in skills assessment and residency training of international medical graduates in Alberta.

Governments and physician organizations in Canada have identified current and anticipated future shortages of physicians. The creation of opportunities for licensure for the sizeable population of unlicensed international medical graduates (IMG) residing in Canada can alleviate some of the shortage of medical manpower. We examine whether expenditures on IMG skills assessment, training and licensing are a socially desirable use of resources. We estimate the financial rate of return to Alberta taxpayers from resources allocated to the Alberta International Medical Graduate (AIMG) program, started in 2001. Our estimates show that resources allocated to providing skills assessment and residency training opportunities for IMGs that lead to licensing as a Canadian physician generate real annual rates of return of 9-13%.

Where Canadian family physicians learn procedural skills.

BACKGROUND AND OBJECTIVES: Little is known about where family physicians learn procedural skills. In this study, we examine where Canadian family medicine graduates learned to do the procedures they perform. METHODS: In 2001, a cross-sectional postal survey was conducted of the 369 family medicine graduates from the University of Alberta and the University of Calgary between 1996 - 2000. From a list of 31 procedures, respondents identified procedures regularly performed over the past 2 years and indicated which procedures they had stopped performing. Respondents indicated whether the procedures performed were learned primarily during medical school and residency, through formal skills training following residency, or in the practice setting. RESULTS: The 282 (76.4% response rate) respondents reported performing a mean of 10.5 (SD=5.3) procedures. The vast majority reported learning procedural skills in medical school or during family medicine residency training (91.1%), followed by the clinical practice setting (12.6%), then formal skills training (6.4%). Those in rural practice learned a relatively greater proportion of procedural skills through formal skills training. CONCLUSIONS: For Canadian family physicians, procedural skill acquisition occurs across the learning continuum. Medical schools and residency training programs play a role in facilitating the learning of procedural skills and supporting self-directed learning.

Canadian and immigrant international medical graduates.

OBJECTIVE: To compare the demographic and educational characteristics of Canadian international medical graduates (IMGs) and immigrant IMGs who applied to the second iteration of the Canadian Resident Matching Service (CaRMS) match in 2002. DESIGN: Web-based questionnaire survey. SETTING: The study was conducted during the second-iteration CaRMS match in Canada. PARTICIPANTS: The sampling frame included the entire population of IMG registrants for the 2002 CaRMS match in Canada who expressed interest in applying for a ministry-funded residency position in the 13 English-speaking Canadian medical schools. Those who immigrated to Canada with medical degrees were categorized as immigrant IMGs. Canadian citizens and landed immigrants or permanent residents who left Canada to obtain a medical degree in another country were defined as Canadian IMGs. MAIN OUTCOME MEASURES: Demographic characteristics, education and training outside Canada, examinations taken, previous applications for a residency position, preferred type of practice, and barriers and supports were compared. RESULTS: Out of 446 respondents who indicated their immigration status and education, 396 (88.8%) were immigrant IMGs and 50 (11.2%) were Canadian IMGs. Immigrant IMGs tended to be older, be married, and have dependent children. Immigrant IMGs most frequently obtained their medical education in Asia, Eastern Europe, the Middle East, or Africa, whereas Canadian IMGs most frequently obtained their medical degrees in Asia, the Caribbean, or Europe. Immigrant IMGs tended to have more years of postgraduate training and clinical experience. A significantly greater proportion of immigrant IMGs had perceived that there were insufficient opportunities for assessment, financial barriers to training, and licensing barriers to practice. Nearly half (45.5%) of all IMGs selected family medicine as their first choice of clinical discipline to practise in Canada. There were no significant differences between Canadian and immigrant IMGs in terms of first choice of clinical discipline (family medicine vs specialty). There were no significant differences between the groups in the number of times they applied to CaRMS in the past, but a relatively greater proportion of Canadian IMGs obtained residency positions. CONCLUSION: There are notable similarities and some significant differences between Canadian and immigrant IMGs seeking to practise medicine in Canada.

Promoting health in type 2 diabetes: nurse-physician collaboration in primary care.

The purpose of this study is to examine effects of a nurse-physician collaborative approach to care of patients with type 2 diabetes and to determine possible effect sizes for use in computing sample sizes for a larger study. Forty patients from a family practice clinic with type 2 diabetes were randomly assigned to control or experimental groups. The control group received standard care, whereas the experimental group received standard care plus home visits from a nurse, as well as consultation with an exercise specialist and/or nutritionist. Follow-up continued for 3 months. Clinical end points included standard measures of diabetes activity as well as quality-of-life indicators. Focus group interviews were used to explore patients' responses to the program. Although findings were not statistically significant, a trend toward small to moderate positive effect sizes was found in glycosylated hemoglobin and blood pressure. Quality of life measures also showed a trend toward small to moderate, but nonsignificant, improvements in physical functioning, bodily pain, vitality, social and global functioning, energy, impact of diabetes, and health distress. Focus group interviews indicated a very positive response from patients, who expressed feelings of empowerment. In this study, patients treated with nurse-physician collaboration demonstrated small, but nonsignificant, improvements in blood chemistry after only 3 months. Physical and social functioning, energy, and bodily pain also showed a small improvement. Changes in awareness of effects of diabetes on health and an expressed sense of self-efficacy suggest that effects could be sustainable over the longer term.

Multi-professional education in diabetes.

Multi-professional education (MPE) is a forward-looking educational strategy that is both innovative and clinically needed. The primary goal of this program was to assess the potential of MPE in diabetes care. Objectives included knowledge increase in type 2 diabetes care and examining the effect of uni-professional versus multi-professional small groups on learning outcomes. A total of 61 baccalaureate nursing students, four pharmacy students and 56 family practice residents participated in a half-day program. Participants were randomly assigned to multi-versus uni-professional groups. A questionnaire assessing knowledge, attitudes and perceived role responsibilities was anonymously completed in a pre-test/post-test manner. The program was delivered in two sessions that combined larger and small group activities. Quantitative data were analyzed using repeated measures Anova/Manova, Wilcoxon signed rank and Pearson chi-square tests. Participants and educators showed interest in multi-professional education. While no change in knowledge was found, moderate changes in attitudes (with a lessening of attitudinal differences) and significant changes in perceptions of role (from uni-professional responsibility to shared responsibilities) were noted. Nurses in uni-professional groups demonstrated the greatest attitudinal and role perception changes. The contribution of the patient as teacher was prominent. Further exploration and rigorous analysis of the utility of MPE in diverse settings is warranted.

Characteristics of international medical graduates who applied to the CaRMS 2002 match.

BACKGROUND: International medical graduates are an important component of the Canadian physician workforce. For most international medical graduates, the principal route to obtaining a residency position in Canada is to apply through the second iteration of the Canadian Resident Matching Service (CaRMS) match. In order to help inform the work toward integrating unlicensed international medical graduates into Canada's health professional workforce, our objectives were to describe the demographic and educational characteristics of international medical graduate CaRMS applicants and identify their preferred clinical disciplines and practice locations. METHODS: A 37-item Web-based questionnaire survey was offered to all 659 international medical graduate second-iteration CaRMS 2002 applicants. We collected data on their demographic and educational background and preferred clinical discipline and practice location. Up to 2 follow-up email reminders were sent to nonrespondents. RESULTS: The survey response rate was 70.3% (463/659). Of the respondents, 71.9% had obtained their medical degree in Asia, the Middle East or Eastern Europe: 36.5% had graduated with a medical degree since 1994, and 17.3% since 1997. Most respondents (74.3%) were aged between 30 and 44 years. More than half (54.6%) had completed their medical education in English. Most (69.3%) had done postgraduate training outside Canada. Before coming to Canada, 42.8% had practised medicine for 1-5 years and 45.6% had practised for 6-20 years. The top 5 choices of clinical discipline in Canada were family medicine/general practice (45.6%), internal medicine (14.9%), surgery (7.3%), obstetrics/gynecology (6.7%) and pediatrics (4.8%). Of those who resided in the 4 Western provinces or Nova Scotia, between 76.8% and 86.7% preferred to stay in their own province, and 60%, 51.4% and 37% of those who resided in Newfoundland, Ontario or Quebec respectively preferred to practise in their own province. INTERPRETATION: Second-iteration international medical graduate CaRMS applicants are a heterogeneous group of physicians, some with substantial medical training and experience and others at an earlier stage of their medical career.