Encouraging residents to seek feedback.

AIM: To explore resident and faculty perceptions of the feedback process, especially residents' feedback-seeking activities. METHODS: We conducted focus groups of faculty and residents exploring experiences in giving and receiving feedback, feedback-seeking, and suggestions to support feedback-seeking. Using qualitative methods and an iterative process, all authors analyzed the transcribed audiotapes to identify and confirm themes. RESULTS: Emerging themes fit a framework situating resident feedback-seeking as dependent on four central factors: (1) learning/workplace culture, (2) relationships, (3) purpose/quality of feedback, (4) emotional responses to feedback. Residents and faculty agreed on many supports and barriers to feedback-seeking. Strengthening the workplace/learning culture through longitudinal experiences, use of feedback forms and explicit expectations for residents to seek feedback, coupled with providing a sense of safety and adequate time for observation and providing feedback were suggested. Tensions between faculty and resident perceptions regarding feedback-seeking related to fear of being found deficient, the emotional costs related to corrective feedback and perceptions that completing clinical work is more valued than learning. CONCLUSION: Resident feedback-seeking is influenced by multiple factors requiring attention to both faculty and learner roles. Further study of specific influences and strategies to mitigate the tensions will inform how best to support residents in seeking feedback.

Deliberative curriculum inquiry for integration in an MD curriculum: Dalhousie University's curriculum renewal process.

BACKGROUND: Dalhousie University's MD Programme faced a one-year timeline for renewal of its undergraduate curriculum. AIM: Key goals were renewed faculty engagement for ongoing quality improvement and increased collaboration across disciplines for an integrated curriculum, with the goal of preparing physicians for practice in the twenty-first century. METHODS: We engaged approximately 600 faculty members, students, staff and stakeholders external to the faculty of medicine in a process described by Harris (1993) as 'deliberative curriculum inquiry'. Temporally overlapping and networked intraprofessional and interprofessional teams developed programme outcomes, completed environment scans of emerging content and best practices, and designed curricular units. RESULTS: The resulting curriculum is the product of new collaborations among faculty and exemplifies distinct forms of integration. Innovations include content and cases shared by concurrent units, foundations courses at the beginning of each year and integrative experiences at the end, and an interprofessional community health mentors programme. CONCLUSION: The use of deliberative inquiry for pre-med curriculum renewal on a one-year time frame is feasible, in part through the use of technology. Ongoing structures for integration remain challenging. Although faculty collaboration fosters integration, a learner-centred lens must guide its design.

Emotional effects of continuity of care on family physicians and the therapeutic relationship.

OBJECTIVE: To explore conceptions of continuity of care among family physicians in traditional practices, family medicine-trained physicians working in episodic care, and family medicine residents to better understand the emotional effects on physicians of establishing long-term relationships with patients as a starting point for developing a tool to measure the qualitative connections between physicians and their patients. DESIGN: Qualitative descriptive study using focus groups. SETTING: Traditional family practice, family medicine residency training, and episodic-care settings in Kingston, Ont. PARTICIPANTS: Three groups of first-year family medicine residents (n = 18), 2 groups of family physicians in established traditional practice (n = 9), and 2 groups of family physicians working in episodic-care settings (n = 10). METHODS: Using focus groups, a semistructured discussion guide, and a phenomenologic approach, we explored residents' and practising physicians' conceptions about continuity of care, predominantly exploring the emotional effects on physicians of providing care for a group of patients over time. MAIN FINDINGS: Providing care for patients over time and developing a deep knowledge of, and often a deep connection to, patients affected physicians in various ways. Most of these effects were rewarding: feelings of connection, trust, curiosity, enhanced professional competence (diagnostically and therapeutically), personal growth, and being cared for and respected. Some, however, were distressing: anxiety, grief, frustration, boundary issues, and negative effects on personal life. CONCLUSION: Family physicians experience myriad emotions connected with providing care to patients. Knowledge of what physicians find rewarding from their long-term connections with patients, and of the difficulties that arise, might be useful in further understanding interpersonal continuity of care and the therapeutic relationship, and in informing resident education about developing therapeutic relationships, evaluating resident educational experiences with continuity of care, and addressing physician burnout.

Two new aspects of continuity of care.

OBJECTIVE: To determine whether the original continuity of care framework is still applicable to family medicine today. DESIGN: Qualitative descriptive study. SETTING: Kingston, Ont. PARTICIPANTS: Three groups of first-year family medicine residents (18 in total), 2 groups of family physicians in established comprehensive practices (9 in total), and 2 groups of family physicians working in episodic care settings (10 in total). METHODS: Using focus groups, a semistructured discussion guide, and a qualitative descriptive design, we explored the residents' and practising physicians' conceptions about continuity of care. Qualitative content analysis was used to identify themes. MAIN FINDINGS: Focus group participants consisting of family physicians providing comprehensive care, episodic care physicians, and family medicine residents exposed 2 new dimensions of continuity of care-community continuity of care (the physicians' roles in understanding the lives of their patients, and how this affects their overall health) and continuity of care within the health care team (the continuity between a patient and members of the interprofessional team, including the family physician). Geographic continuity of care (the care of a patient in various settings by the same physician) was not prominently discussed, perhaps reflecting the paucity of family physicians in the hospital setting. CONCLUSION: Both of these new dimensions of continuity of care are consistent with the ongoing evolution of family medicine as a discipline, and have important implications for how family medicine training programs should be designed to best prepare trainees for future practice.

Fundamental Teaching Activities in Family Medicine Framework: Analysis of Awareness and Utilization.

INTRODUCTION: In 2015, the College of Family Physicians of Canada, in performing their commitment to supporting its members in their educational roles, created the Family Medicine Framework (FTA). It was designed to assist family medicine educators with an understanding of the core activities of educators: precepting, coaching, and teaching within or beyond clinical settings. Given that an examination of member awareness of FTA has not been previously undertaken, our primary objective was to conduct an evaluation on its utility and application. METHODS: In partnership with College of Family Physicians of Canada Faculty Development Education Committee members, we used a practical participatory evaluation approach to conduct a two-phase mixed-methods evaluation of the FTA. We distributed an electronic survey in French and English languages to Canadian faculty development, program, and site directors in family medicine. We then conducted follow-up interviews with self-selected participants. RESULTS: Of the target populations, 12/15 (80%) faculty development directors (FDDs), 12/18 (66.7%) program directors, and 34/174 (19.5%) site directors completed the electronic survey. Subsequently, 6 FDDs, 3 program directors, and 3 site directors completed an interview (n = 12). Findings indicate that awareness of the FTA was highest among FDDs. Facilitators who encourage teachers to use the FTA and barriers for low uptake were also identified. DISCUSSION: This evaluation illuminated that varied levels of awareness of the FTA may contribute to the low uptake among education leaders. We also suggest future research to address possible barriers that hinder effective applications of the FTA in faculty development initiatives.

Manual and automated office measurements in relation to awake ambulatory blood pressure monitoring.

BACKGROUND: Automated blood pressure (BP) devices are commonly used in doctor's offices. How BP measured on these devices relates to ambulatory BP monitoring is not clear. OBJECTIVE: To assess how well office-based manual and automated BP predicts ambulatory BP. METHODS: Using data on 654 patients, we assessed how well sphygmomanometer measurements and measurements taken with an automated device (BpTRU) predicted results on ambulatory BP monitoring. We assess positive and negative predictive values and overall accuracy. We look at different cut-points for systolic (130, 135 and 140 mmHg) and diastolic (80, 85 and 90 mmHg) BP. RESULTS: A single automated office BP (AOBP) assessment provides superior predictive values and overall accuracy compared to three manual office BP assessments. For systolic BP, the predictive values are ≤69% for any of the cut-points while the positive predictive values for the single automated measurement is between 80.0% and 86.9% and the overall accuracy gets as high as 74% for the 130 mmHg cut-point. For diastolic BP, the automated readings are also more predictive but in this case, it is the negative predictive values that are better, as well as the overall accuracy. CONCLUSIONS: Based on the results, we suggest that 135/85 mmHg continue to be used as the cut-point defining high BP with the BpTRU device. However, future research might suggests that values in a grey zone between 130-139 mmHg systolic and 80-89 mmHg diastolic be confirmed using ambulatory BP monitoring. As well, three AOBP assessments might produce much greater accuracy than the single AOBP assessment used in the study.

Continuity of care: differing conceptions and values.

OBJECTIVE: To understand how the conception of continuity of care can influence family physician trainees by exploring the perspectives of established family physicians, physicians working in episodic care who had been trained in family medicine, and family medicine trainees. DESIGN: Qualitative analysis of focus group data. SETTING: Southeastern Ontario. PARTICIPANTS: Seven focus groups consisting of members from 3 groups: established family physicians, physicians working in episodic care who had been trained in family medicine, or family medicine trainees. METHODS: Semistructured focus group interviews were taped and transcribed. Using constant comparison, the transcripts were analyzed for themes related to continuity of care and how these were valued among the 3 groups of physicians. MAIN FINDINGS: The 3 groups differed on how they valued continuity of the relationship, how they valued informational continuity, and how these concepts affected their perceptions of difficult clinician-patient relationships. Experienced family physicians described long-term relationships as a core value in their practices. In contrast, episodic care physicians valued informational continuity. Family medicine trainees learned about continuity of care through role models and theoretical teaching. They valued the efficiency gained by knowing patients and the reward of being recognized by patients. Family medicine trainees expressed greater distress with difficult clinician-patient interactions than experienced family physicians expressed. It was unclear whether the challenges of difficult relationships were offset by the trainees' appreciation of continuity of care. CONCLUSION: Different perceptions, settings, and skills can influence how continuity of care is valued, which might affect career and practice decisions among trainees.

Effectiveness of a protocol-based strategy for achieving better blood pressure control in general practice.

BACKGROUND: There continues be a problem with the proportion of treated hypertension patients who are actually at recommended blood pressure targets. OBJECTIVE: Is an intensive protocol-based strategy for achieving blood pressure control effective in family practice and will family physicians and their hypertensive patients adhere to such a protocol. METHODS: Design of the study is a cluster randomized controlled trial at the Centre for Studies in Primary Care, Queen's University, Kingston, Ontario. Participants were 19 family physicians and 156 (98 intervention group and 58 control group) of their patients in and around the Kingston area. Patients were eligible if they had a diagnosis of hypertension and had not yet achieved their target blood pressure. Patients in the intervention group were managed according to a protocol that involved seeing their family doctor every 2 weeks over a 16-week period and having their antihypertensive medication regimen adjusted at each visit if target was not achieved. This was compared to usual care. Main outcomes were primary effectiveness outcome measured at 12 months was the differences in blood pressure between baseline and 12 months in the two groups. Secondary effectiveness outcomes included rates of achieving BP target and compliance with protocol by physicians and patients. Adherence outcomes were assessed by determining the number of visits made during the 16-week intervention period and the increase in the number of drugs being used. RESULTS: Of the patients enrolled, 72 (74%) from the intervention group and 41 (71%) in the control group were available for analysis. Improvement between baseline and 12-month follow-up was significantly better for the intervention group than the control for diastolic mean daytime BP on 24 hours ambulatory blood pressure monitoring (4.5 mmHg reduction versus 0.5 mmHg reduction) and for both systolic (14.7 mmHg reduction versus 2.7 mmHg reduction) and diastolic (7.4 mmHg reduction versus 0.6 mmHg increase) blood pressure on BpTRU. Of the 98 patients in the intervention, 80% attended four or more of the eight visits and 25% attended all eight visits; physicians increased the number or dosage of drugs the patient was taking in 52% of the visits. Conclusions. An intensive, protocol-based, management approach to achieving blood pressure control in hypertensive patients in family practice is effective and works even when there is flexibility built into the algorithm to allow family physicians to use their judgement in individual patients.

A primary care pragmatic cluster randomized trial of the use of home blood pressure monitoring on blood pressure levels in hypertensive patients with above target blood pressure.

BACKGROUND: The measurement of blood pressure (BP) at home by patients with hypertension is increasingly used to assess and monitor BP. Evidence for its effectiveness in improving BP control is mixed. METHODS: To determine if home BP monitoring improves BP a pragmatic cluster randomized contolled trial was carried out in family practices in southeastern Ontario, Canada. Family practice patients with uncontrolled hypertension were recruited to the trail. Patients were divided into two groups: one with at least weekly measurements of BP at home, recording those measurements and showing those to the family physician during office visits for hypertension and the control group were given usual care. The primary outcome was mean awake BP on ambulatory monitoring at 6- and 12-month follow-up and the secondary outcomes were mean BP on full 24-hour ambulatory blood pressure monitoring (ABPM), mean sleep BP on ABPM and BP on the BpTRU device, all at 6- and 12-month follow-up. RESULTS: Home BP monitoring did not improve BP compared to usual care at 12-month follow-up: mean awake systolic BP on ABPM [141.1 versus 142.8 mmHg, mean difference 1.7 mmHg; 95% confidence interval (CI) -0.6 to 4.0, P = 0.314] and mean awake diastolic BP on ABPM (78.7 versus 79.4 mmHg, mean difference 0.7 mmHg; 95% CI -7.7 to 9.1, P = 0.398). Similar negative results were obtained for men and women separately. However, outcomes using the full 24-hour ABPM and the BpTRU device showed a significantly lower diastolic BP at 12 months. When analysis was done by sex, this effect was shown to be only in men. CONCLUSION: Home BP monitoring may improve BP control in men with hypertension.

Implementing Competency-Based Medical Education in Family Medicine: A Scoping Review on Residency Programs and Family Practices in Canada and the United States.

BACKGROUND AND OBJECTIVES: While family medicine has been one of the first specialties to implement competency-based medical education (CBME) in residency, the nature and level of its integration with continuing professional development (CPD) is neither well understood nor well studied. The purpose of this review was to examine the current state of CBME implementation in family medicine residency and CPD programs in the North American education literature, with the aim of identifying implementation concepts and strategies that are generalizable to other medical settings to inform the design and implementation of residency training and CPD. METHODS: Using an Arksey and O'Malley six-step framework, we searched five online databases and the gray literature over the period between January 2000 through April 2017. We included full-text articles that focused on the key words CBME, residency, CPD, and family medicine. RESULTS: Of the articles reviewed, 37 met the inclusion criteria and were selected for full review. Eighty six percent of included articles focused on foundation elements related to designing competency-based curriculum and assessment strategies rather than program evaluation or other outcome measures. Only 19% of the articles were related to CPD that focused only on the implementation at the program and/or institution/organization levels. CONCLUSIONS: Given that the implementation of CBME is in its relative infancy, the pattern of implementation activities described in this scoping review reflected a limited focus on a broad range of issues related to fidelity of implementation of this complex intervention.

Twelve tips for bringing competencies into continuing professional development: Curriculum mapping.

This article was migrated. The article was marked as recommended. There is a growing worldwide awareness in the field of health professions education and research that a successful implementation of competency-based medical education (CBME) requires embracing all stages of professional development (from undergraduate, through residency to continuing education). However, despite increased levels of cognizance and even enthusiasm about the importance of the entire continuum for the ultimate goal of improved healthcare, much work still remains as CBME principles are not widely adopted in continuing professional development (CPD). Much has been written about the process of competency-based curriculum development (e.g., the formation and development of meaningful and measurable outcomes) in undergraduate studies and postgraduate training, but not in CPD. If we expect a CPD curriculum to integrate CBME, competencies must be developed and clearly specified how they will fit into a coherent and implementable curriculum structure. In this article, we describe existing practices some educational institutions have, including our experiences in the Office of CPD at the University of Ottawa, Canada, in designing a competency-based curriculum and provide 12 tips for those who begin their journey of organizing, developing, and implementing such curricula. We conclude that in order to translate a competency-based approach into CPD, educational programs will have to refine curricula across health professionals' education using curriculum mapping as an important tool of curriculum development and evaluation.

Team effectiveness in academic primary health care teams.

Primary health care is undergoing significant organizational change, including the development of interdisciplinary health care teams. Understanding how teams function effectively in primary care will assist training programs in teaching effective interprofessional practices. This study aimed to explore the views of members of primary health care teams regarding what constitutes a team, team effectiveness and the factors that affect team effectiveness in primary care. Focus group consultations from six teams in the Department of Family Medicine at Queen's University were recorded and transcribed and qualitative analysis was used to identify themes. Twelve themes were identified that related to the impact of dual goals/obligations of education and clinical/patient practice on team relationships and learners; the challenges of determining team membership including nonattendance of allied health professionals except nurses; and facilitators and barriers to effective team function. This study provides insight into some of the challenges of developing effective primary care teams in an academic department of family medicine. Clear goals and attention to teamwork at all levels of collaboration is needed if effective interprofessional education is to be achieved. Future research should clarify how best to support the changes required for increasingly effective teamwork.

A new model for collaborative continuing professional development.

For collaborative patient-centered practice models to develop, improved collaboration in the workplace is needed. In this project we aimed to create a model of continuing professional development (CPD) using a case based approach that would allow the exchange of information between primary health care providers in the community. Over 60 participants from community care sectors including physicians, nurses and administrators participated in a planning group and two consultation workshops. Using participatory action research methods, themes contributing to and inhibiting communication, collaboration and coordination of care in the community were identified. Recommendations for solutions were prioritized and implemented. Evaluations suggest that the case scenario and consultation approach successfully focused participants to address relevant local issues to improve collaboration among community providers.

The difference between medical students interested in rural family medicine versus urban family or specialty medicine.

OBJECTIVE: To determine how first-year medical students interested in rural family medicine in Canada differ from their peers. METHOD: From 2002 to 2004, first-year students (n = 2189) from 16 classes in 8 Canadian medical schools ranked intended career choices and indicated influences on their choices using Likert scales. We used t tests and chi2 tests to determine demographic influences and factor analysis, and we used analysis of variance to examine associated attitudes. RESULTS: Of the 1978 surveys returned (90.3%), 1905 were used in the analysis. Rural family medicine was ranked first by 11.1%, varying from 4.7% to 20.2% among schools. Students interested in rural family medicine were more likely to have grown up rurally, graduated from a rural high school and have family in a rural location than others (p < 0.001). They were more likely to be older, in a relationship, to have volunteered in a developing nation and less likely to have university-educated parents than those interested in a specialty (p < 0.008). Attitudes of students choosing family medicine, rural or urban, include social orientation, preference for a varied scope of practice and less of a hospital orientation or interest in prestige, compared with students interested in specialties (p < 0.001). CONCLUSION: Medical schools may address the rural physician shortages by considering student demographic factors and attitudes at admission.

Pragmatic controlled clinical trials in primary care: the struggle between external and internal validity.

BACKGROUND: Controlled clinical trials of health care interventions are either explanatory or pragmatic. Explanatory trials test whether an intervention is efficacious; that is, whether it can have a beneficial effect in an ideal situation. Pragmatic trials measure effectiveness; they measure the degree of beneficial effect in real clinical practice. In pragmatic trials, a balance between external validity (generalizability of the results) and internal validity (reliability or accuracy of the results) needs to be achieved. The explanatory trial seeks to maximize the internal validity by assuring rigorous control of all variables other than the intervention. The pragmatic trial seeks to maximize external validity to ensure that the results can be generalized. However the danger of pragmatic trials is that internal validity may be overly compromised in the effort to ensure generalizability. We are conducting two pragmatic randomized controlled trials on interventions in the management of hypertension in primary care. We describe the design of the trials and the steps taken to deal with the competing demands of external and internal validity. DISCUSSION: External validity is maximized by having few exclusion criteria and by allowing flexibility in the interpretation of the intervention and in management decisions. Internal validity is maximized by decreasing contamination bias through cluster randomization, and decreasing observer and assessment bias, in these non-blinded trials, through baseline data collection prior to randomization, automating the outcomes assessment with 24 hour ambulatory blood pressure monitors, and blinding the data analysis. SUMMARY: Clinical trials conducted in community practices present investigators with difficult methodological choices related to maintaining a balance between internal validity (reliability of the results) and external validity (generalizability). The attempt to achieve methodological purity can result in clinically meaningless results, while attempting to achieve full generalizability can result in invalid and unreliable results. Achieving a creative tension between the two is crucial.