Advancing anti-oppression and social justice in healthcare through competency-based medical education (CBME).

Competency-based medical education (CBME) focuses on preparing physicians to improve the health of patients and populations. In the context of ongoing health disparities worldwide, medical educators must implement CBME in ways that advance social justice and anti-oppression. In this article, authors describe how CBME can be implemented to promote equity pedagogy, an approach to education in which curricular design, teaching, assessment strategies, and learning environments support learners from diverse groups to be successful. The five core components of CBME programs - outcomes competency framework, progressive sequencing of competencies, learning experiences tailored to learners' needs, teaching focused on competencies, and programmatic assessment - enable individualization of learning experiences and teaching and encourage learners to partner with their teachers in driving their learning. These educational approaches appreciate each learner's background, experiences, and strengths. Using an exemplar case study, the authors illustrate how CBME can afford opportunities to enhance anti-oppression and social justice in medical education and promote each learner's success in meeting the expected outcomes of training. The authors provide recommendations for individuals and institutions implementing CBME to enact equity pedagogy.

Conceptualizing "Preparedness for Practice": Perspectives of Early-Career Family Physicians.

BACKGROUND AND OBJECTIVES: Competency based medical education (CBME) aims to produce graduates prepared for independent practice. Many equate the outcome of "preparedness for practice" with acquisition of competence. As educators evaluate the outcomes of CBME, being clear on the concept of preparedness for practice will clarify the results that are measured and assessed. This study examined how preparedness for practice is conceptualized in the literature and by family physicians (FPs) in Canada. METHODS: This multimethod qualitative descriptive study included (1) rapid review and narrative synthesis, and (2) focus groups with early-career FPs using maximum variation sampling until thematic saturation was reached. Focus groups explored the FPs' conceptualizations of preparedness for practice. Focus groups were audio-recorded, transcribed, and coded before content analysis. RESULTS: Thirty-four articles met the inclusion criteria, and 59 early-career FPs participated in the focus groups. We found no consensus on the conceptualization of preparedness for practice in the literature; however, the concept often was described as acquiring competencies for program requirements. In the literature and focus groups, we identified four themes for the conceptualization of preparedness for practice. These themes included competence, self-confidence (self-efficacy, self-concept), capability, and adaptability. CONCLUSIONS: Preparedness for practice involves an interplay of dynamic and complex constructs from competence, self-confidence, capability, and adaptability. Preparedness is more than possessing several competencies; it calls for integrating and applying competencies in complex and changing environments. This study aimed to start a discussion on what end point is desirable for residency education and proposed that the end point needs to move beyond competencies.

The Rural Road Map For Action: an examination of undergraduate medical education in Canada.

Background: There is currently a maldistribution of physicians across Canada, with rural areas facing a greater physician shortage. The taskforce between the College of Family Physicians and the Society of Rural Physicians created a report, "The Rural Road Map for Action" (RRMA) to improve rural Canadians' health by training and retaining an increased number of rural family physicians. Using the RRMA as a framework, this paper aims to examine the extent to which medical schools in Canada are following the RRMA. Methods: Researchers used cross-sectional survey and collected data from 12 of 17 medical school undergraduate Deans from across Canada using both closed and open ended survey questions. Results were analyzed using quantitative (frequencies) and qualitative methods (content analysis). Results: Medical schools use different policies and procedures to recruit rural and Indigenous students. Although longitudinal integrated clerkships offer many benefits, few students have access to them. Leadership representation on decision-making education committees differed across medical schools pointing to a variation in the value of rural physicians' perspectives. Conclusion: This study illustrated that medical schools are making efforts that align with the RRMA. It is critical they continue to make strategic decisions embedded in educational policy and leadership to reinforce the importance of and influence of rural medical education to support workforce planning.

Contexte: À l'heure actuelle, la répartition des médecins sur le territoire canadien est inégale, les régions rurales étant confrontées à une plus forte pénurie de médecins. Le groupe de travail constitué par le Collège des médecins de famille du Canada (CMFC) et la Société de la médecine rurale du Canada (SMRC) a produit un rapport intitulé « Plan d'action pour la médecine rurale ¼ (PAMR) qui vise à améliorer la santé des Canadiens vivant en milieu rural par la formation et la rétention d'un nombre accru de médecins de famille en milieu rural. Cet article évalue dans quelle mesure les facultés de médecine du Canada suivent les recommandations du PAMR. Méthodes: Les chercheurs ont eu recours à une enquête transversale, comportant des questions fermées et ouvertes, pour recueillir des données auprès de 12 des 17 doyens aux études de premier cycle des facultés de médecine canadiennes. Les résultats ont été analysés à l'aide de méthodes quantitatives (calcul des fréquences) et qualitatives (analyse de contenu). Résultats: Les facultés de médecine appliquent des politiques et des procédures différentes pour recruter des étudiants d'origine rurale ou autochtone. Les externats longitudinaux intégrés offrent de nombreux avantages, mais peu d'étudiants y ont accès. La diversité au sein des comités pédagogiques décisionnels est si variable que l'on peut en déduire que le point de vue des médecins exerçant en milieu rural n'est pas toujours valorisé. Conclusion: Cette étude montre que les facultés de médecine déploient des initiatives qui sont conformes au PAMR. Il est essentiel que leurs décisions stratégiques demeurent ancrées dans un leadership et une politique éducative visant à renforcer et à mettre en valeur l'exposition des étudiants à la médecine rurale pour soutenir la planification des effectifs.

Examining the status of rural post-graduate family medicine education.

Introduction: Rural populations in Canada are generally in worse health when compared to their urban counterparts. In 2014, the College of Family Physicians of Canada and the Society of Rural Physicians of Canada formed a joint Task force to advocate for improved health in rural communities. As a task force, they developed the Rural Road Map for Action. This paper uses the Rural Road Map for Action as a framework to examine the current state of family medicine's Post-Graduate Medical Education (PGME) in Canada. Methods: Surveys were sent to the programme directors of all English- and French-speaking post-graduate family medicine programmes. Both quantitative and qualitative methods were used to analyse survey responses. Results: Thirteen of 17 respondents completed the questionnaire. Despite on-going efforts, our results suggest that few programmes have equity and diversity admission's policies for rural and Indigenous students; a gap exists between the number of residents who are educated in rural areas and those who end up practising in rural areas; residents lack skills in Indigenous health; and more funded professional development opportunities are needed for rural physicians. Conclusion: Rural healthcare concerns are typically under-represented in PGME. The Rural Road Map for Action brings focus to the specific healthcare needs of rural areas, highlighting a recruitment and retention strategy that aligns education, practice, policy and research activities. Medical schools and national physician organisations need to continue to advocate for the health of rural communities through increasing the rural physician workforce and providing appropriate training for rural practice.

Résumé Introduction: Les populations rurales du Canada sont généralement en moins bonne santé que leurs homologues urbaines. En 2014, le Collège des médecins de famille du Canada et la Société de la médecine rurale du Canada ont formé un groupe de travail conjoint pour défendre l'amélioration de la santé dans les collectivités rurales. En tant que groupe de travail, ils ont élaboré le Plan d'action pour la médecine rurale. Le présent document utilise ce Plan comme cadre pour examiner l'état actuel de la formation médicale postuniversitaire (FMP) de la médecine familiale au Canada. Méthodes: Les enquêtes ont été envoyées aux directeurs de programme de tous les programmes de médecine familiale postuniversitaire anglophones et francophones. Des méthodes quantitatives et qualitatives ont été utilisées pour analyser les réponses. Résultats: Treize des 17 répondants ont rempli le questionnaire. Malgré les efforts en cours, nos résultats suggèrent que peu de programmes ont des politiques d'admission en matière d'équité et de diversité pour les étudiants ruraux et autochtones; un écart existe entre le nombre de résidents qui sont formés dans les zones rurales et ceux qui finissent par exercer dans ces zones; les résidents manquent de compétences en matière de santé autochtone et; que davantage d'opportunités de développement professionnel financées sont nécessaires pour les médecins ruraux. Conclusion: Les préoccupations relatives aux soins de santé en milieu rural sont généralement sous-représentées dans la FMP. Le Plan d'action pour la médecine rurale met l'accent sur les besoins spécifiques des zones rurales en matière de soins de santé, en soulignant une stratégie de recrutement et de rétention qui aligne les activités d'éducation, de pratique, de politique et de recherche. Les facultés de médecine et les organisations nationales de médecins doivent continuer à défendre la santé des collectivités rurales en augmentant le nombre de médecins ruraux et en offrant une formation appropriée à la pratique rurale. Mots-clés: éducation médicale rurale, plan d'action pour la médecine rurale, santé rurale.

Practice Profiles and Patterns of Ontario Family Medicine Residents 5 Years After Residency Examinations: An Exploratory Study.

BACKGROUND AND OBJECTIVES: The primary goal of family medicine residency training is for graduates to provide high-quality, safe, and effective patient care for the population they serve when they enter practice. This study explores (a) the practice profiles, 5 years into practice, of residents who completed family medicine training in Ontario, Canada; and (b) relationships between performance on the College of Family Physicians of Canada's (CFPC) Certification Examination in Family Medicine and quality of care provided 5 years into practice. METHODS: We performed a retrospective study with secondary data analysis. We merged CFPC examination data sets with the ICES (Institute for Clinical Evaluative Sciences) administrative database. We included physicians who passed the examination between the years 2000 and 2010 and practiced in Ontario after graduation. Practice profile indicators included practice type, continuity and comprehensiveness of care, patient rostering and panel size, and rurality index. We explored 11 indicators related to management of diabetes and cancer screening. RESULTS: We included a total of 1,983 physicians in the analyses. Five years after the examinations, 74.3% of the physicians were working in major urban centers, and 67.3% of the physicians were providing comprehensive primary care. We noted significant differences across the six medical schools in multiple practice profile indicators, and three indicators showed significant differences across the examination score quintiles. CONCLUSIONS: Graduates of Ontario family medicine residency programs were providing care to a broad spectrum of the population 5 years after passing the examination, and they performed similarly across quality-of-care indicators regardless of examination scores.

Current State of Quantitative Data Available for Examining the Work of Family Physicians in Canada.

In Canada, there is no single source of data describing the number, distribution and work of family physicians (FPs). This study examines the state of national and provincial/territorial data sources for FPs in comparison with the College of Family Physicians of Canada's Family Medicine Professional Profile. Data sources were assessed through key informant interviews and document analysis. Findings indicate that there is significant variability on what is measured across jurisdictions, resulting in comparability challenges. A measurement framework that accurately describes the number, distribution and work of FPs with a pan-Canadian data collection strategy is urgently needed for effective health human resource planning.

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.

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.

Process and outcome evaluation of a CBME intervention guided by program theory.

RATIONALE: Competency-based medical education (CBME) has gained momentum as an improved training model, but literature on outcomes of CBME, including evaluation of implementation processes, is minimal. We present a case for the following: (a) the development of a program theory is essential prior to or in the initial stages of implementation of CBME; (b) the program theory should guide the strategies and methods for evaluation that will answer questions about anticipated and unintended outcomes; and (c) the iterative process of testing assumptions and hypotheses will lead to modifications to the program theory to inform best practices of implementing CBME. METHODS: We use the Triple C Competency-based Curriculum as a worked example to illustrate how process and outcome evaluation, guided by a program theory, can lead to meaningful enhancement of CBME curriculum, assessment, and implementation strategies. Using a mixed methods design, the processes and outcomes of Triple C were explored through surveys, interviews, and historical document review, which captured the experiences of various stakeholders. FINDINGS: The theory-led program evaluation process was able to identify areas that supported CBME implementation: the value of a strong nondirective national vertical core supporting the transformation in education, program autonomy, and adaptability to pre-existing local context. Areas in need of improvement included the need for ongoing support from College of Family Physicians of Canada (CFPC) and better planning for shifts in program leadership over time. CONCLUSIONS: Deliberately pairing evaluation alongside change is an important activity and, when accomplished, yields valuable information from the experiences of those implementing and experiencing a program. Evaluation and the development of an updated program theory facilitate the introduction of new changes and theories that build on these findings, which also supports the desired goal of contributing toward cumulative science rather than "reinventing the wheel."

Twelve tips for improvement-oriented evaluation of competency-based medical education.

The shift to competency-based medical education (CBME) requires a new approach to program evaluation. CBME implementers need to embed evaluation in their programs to ensure their CBME adapts to the changing demands of the healthcare system. This 12 tips paper proposes that those advancing CBME use an improvement-oriented, utilization-focused approach to program evaluation. This will yield information that can help CBME implementers to continually examine the context, process and early outcomes of their programs. The paper uses examples from the College of Family Physicians of Canada's (CFPC's) evaluation of the implementation of the Triple C Competency-based curriculum in family medicine residency programs across Canada. These practical tips will be useful to medical educators looking to integrate evaluation into their CBME programs and to those considering other curriculum reform in health professions education.

A systematic review of reviews: Recruitment and retention of rural family physicians.

INTRODUCTION: The recruitment and retention of family physicians in rural and remote communities has been the topic of many reviews; however, a lack of consensus among them with regard to which factors are most influential makes it difficult for setting priorities. We performed a systematic review of reviews which helped to establish an overall conclusion and provided a set of fundamental influential factors, regardless of the consistency or generalisability of the findings across reviews. This review also identified the knowledge gaps and areas of priority for future research. METHODS: A literature search was conducted to find the review articles discussing the factors of recruitment or retention of rural family physicians. Results were screened by two independent reviewers. The number of times that each factor was mentioned in the literature was counted and ordered in terms of frequency. RESULTS: The literature search identified 84 systematic reviews. Fourteen met the inclusion criteria, from which 158 specific factors were identified and summarised into 11 categories: personal, health, family, training, practice, work, professional, pay, community, regional and system/legislation. The three categories referenced most often were training, personal and practice. The specific individual factors mentioned most often in the literature were 'medical school characteristics', 'longitudinal rural training' and 'raised in a small town'. CONCLUSION: The three most often cited categories resemble three distinct phases of a family physician's life: pre-medical school, medical school and post-medical school. To increase the number of physicians who choose to work in rural practice, strategies must encompass and promote continuity across all three of these phases. The results of this systematic review will allow for the identification of areas of priority that require further attention to develop appropriate strategies to improve the number of family physicians working in rural and remote locations.

Résumé Introduction: Le recrutement et la rétention des médecins de famille dans les communautés rurales et éloignées ont fait l'objet de nombreuses revues; il est toutefois difficile d'établir les priorités en la matière en raison de l'absence de consensus quant aux facteurs ayant la plus grande influence. Nous avons mené une revue systématique des revues qui nous a aidés à tirer une conclusion d'ensemble et à réunir une série de facteurs fondamentaux d'influence, sans égard à l'uniformité des observations des revues ni à la possibilité de les généraliser. Les résultats de cette revue systématique nous permettront de déterminer quels sont les domaines prioritaires auxquels nous devons nous attarder dans le but d'élaborer les stratégies appropriées qui multiplieront le nombre de médecins de famille en région rurale ou éloignée. Cette revue a aussi fait ressortir les lacunes et les domaines prioritaires en recherche. Méthodologie: La littérature publiée a été recherchée pour trouver les articles de synthèse traitant des facteurs de recrutement ou de rétention des médecins de famille en région rurale. Les résultats ont été dépouillés par deux réviseurs indépendants. Le nombre de fois où chaque facteur était mentionné dans les publications était compté et classé en fonction de la fréquence. Résultats: La recherche de la littérature a relevé 84 revues systématiques. Quatorze répondaient aux critères d'inclusion; de celles-là, 158 facteurs ont été définis et résumés en 11 catégories : personnel, santé, famille, formation, pratique, travail, professionnel, rémunération, communauté, régional et système/législation. Les trois catégories qui sont revenues le plus souvent étaient formation, personnel et pratique. Les facteurs individuels mentionnés le plus souvent dans la littérature étaient" caractéristiques de l'école de médecine", "formation rurale longitudinale" et "grandi dans un village". Conclusion: Les trois catégories citées le plus souvent ressemblent à trois phases distinctes de la vie d'un médecin de famille : avant l'école de médecine, école de médecine et après l'école de médecine. Pour augmenter le nombre de médecins qui choisissent la pratique rurale, les stratégies doivent inclure et favoriser la continuité entre ces trois phases. Mots-clés: médecin de famille, recrutement, rétention, rural, revue systématique de revues.

Exploring Change After Implementation of Family Medicine Residency Curriculum Reform.

BACKGROUND AND OBJECTIVES: In 2010, the College of Family Physicians of Canada (CFPC) launched its competency-based medical education (CBME) approach to residency curriculum and assessment. Named Triple C, this innovation was developed to ensure graduates of family medicine training programs are competent to begin unsupervised practice. Further, Triple C was intended to promote interest in practicing comprehensive family medicine. A program evaluation plan was launched by the CFPC alongside the implementation of Triple C to explore if intended outcomes were achieved. METHODS: We conducted retrospective secondary data analysis of survey findings from graduating family medicine residents from two sources: National Physician Survey (NPS 2007 and 2010); and the Family Medicine Longitudinal Survey (FMLS 2015). Demographics and practice intentions reported by residents in the NPS 2007, NPS 2010, and FMLS 2015 were included in the analyses and a comparison between years was undertaken using a series of Pearson χ2 test. RESULTS: Findings indicate that in comparison to pre-Triple C (NPS 2007 and NPS 2010), significantly more residents reported the intention to include palliative care, intrapartum care, in-patient hospital care, care in the home, and practicing in rural settings after the implementation of Triple C (FMLS 2015; P<0.01). CONCLUSIONS: Family medicine graduates report an increase in intention to include a broader range of clinical domains after implementation of Triple C. While a causal relationship cannot be determined, using a historical control in the form of survey data that predates Triple C implementation could support future approaches to evaluation of education reform.

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.