International medical graduates' experiences with caring for cross-cultural patient populations: Qualitative study in Alberta.

OBJECTIVE: To explore experiences of international medical graduate (IMG) FPs in providing cross-cultural patient care and to identify rewards and challenges they experienced when caring for patients of cultural backgrounds different from their own. DESIGN: Descriptive qualitative study. SETTING: Family medicine primary care practices in Alberta. PARTICIPANTS: Eighteen IMG FPs practising in the metropolitan areas of Edmonton or Calgary in Alberta as of May 2013. METHODS: Individual face-to-face or telephone interviews were conducted using a semistructured interview guide. Seventeen interviews occurred between July and August 2013 and 1 took place in August 2014. All interviews were audiorecorded and transcribed verbatim. Transcribed data were subject to thematic analysis. MAIN FINDINGS: International medical graduates identified several rewarding aspects of caring for patients with cultural backgrounds different from their own, including learning about different cultures, perceiving that appointments are more succinct, and advocating for patients whom they perceive to be at a disadvantage. Family physicians also identified several challenges associated with caring for patients of different cultural backgrounds, including encountering language barriers, perceiving that visits take longer, and experiencing patients' lack of acceptance of FPs with cultural backgrounds different from their own. CONCLUSION: Cultural differences between FPs and patients can enhance or undermine doctor-patient relationships. The results of this study speak to the need for cultural competency training for FPs practising in culturally diverse settings.

Intimidation, harassment, and discrimination during family medicine residency training: a mixed methods study.

BACKGROUND: The importance of wellbeing of family medicine residents is recognized in accreditation requirements which call for a supportive and respectful learning environment; however, concerns exist about learner mistreatment in the medical environment. The purpose of this study was to to describe family medicine graduates' perceived experience with intimidation, harassment and discrimination (IHD) during residency training. METHODS: A mixed-methods study was conducted on a cohort of family medicine graduates who completed residency training during 2006-2011. Phase 1, the quantitative component, consisted of a retrospective survey of 651 graduates. Phase 2, the qualitative component, was comprised of 11 qualitative interviews. Both the survey and the interviews addressed graduates' experience with IHD with respect to frequency and type, setting, perpetrator, perceived basis for IHD, and the effect of the IHD. RESULTS: The response rate to the survey was 47.2%, with 44.7% of respondents indicating that they experienced some form of mistreatment/IHD during residency training, and 69.9% noting that it occurred more than once. The primary sources of IHD were specialist physicians (75.7%), hospital nurses (47.8%), and family physicians (33.8%). Inappropriate verbal comments were the most frequent type of IHD (86.8%). Graduates perceived the basis of the IHD to be abuse of power (69.1%), personality conflict (36.8%), and family medicine as a career choice (30.1%), which interview participants also described. A significantly greater proportion IMGs than CMGs perceived the basis of IHD to be culture/ethnicity (47.2% vs 10.5%, respectively). The vast majority (77.3%) of graduates reported that the IHD experience had a negative effect on them, consisting of decreased self-esteem and confidence, increased anxiety, and sleep problems. As trainees, they felt angry, threatened, demoralized, discouraged, manipulated, and powerless. Some developed depression or burnout, took medication, or underwent counselling. CONCLUSIONS: IHD continued to be prevalent during family medicine residency training, with it occurring most frequently in the hospital setting and specialty rotations. Educational institutions must work with hospital administrators to address issues of mistreatment in the workplace. Residency training programs and the medical establishment need to be cognizant that the effects of IHD are far-reaching and must continuously work to eradicate it.

Interprofessional collaboration in diabetes care: perceptions of family physicians practicing in or not in a primary health care team.

BACKGROUND: In Canada, most patients with type 2 diabetes mellitus (T2DM) are cared for in the primary care setting in the practices of family physicians. This care is delivered through a variety of practice models ranging from a single practitioner to interprofessional team models of care. This study examined the extent to which family physicians collaborate with other health professionals in the care of patients with T2DM, comparing those who are part of an interprofessional health care team called a Primary Care Network (PCN) to those who are not part of a PCN. METHODS: Family physicians in Alberta, Canada were surveyed to ascertain: which health professionals they refer to or have collaborative arrangements with when caring for T2DM patients; satisfaction and confidence with other professionals' involvement in diabetes care; and perceived effects of having other professionals involved in diabetes care. Chi-squared and Fishers Exact tests were used to test for differences between PCN and non-PCN physicians. RESULTS: 170 (34%) family physicians responded to the survey, of whom 127 were PCN physicians and 41 were non-PCN physicians (2 not recorded). A significantly greater proportion of PCN physicians vs non-PCN physicians referred patients to pharmacists (23.6% vs 2.6%) or had collaborative working arrangements with diabetes educators (55.3% vs 18.4%), dietitians (54.5% vs 21.1%), or pharmacists (43.1% vs 21.1%), respectively. Regardless of PCN status, family physicians expressed greater satisfaction and confidence in specialists than in other family physicians or health professionals in medication management of patients with T2DM. Physicians who were affiliated with a PCN perceived that interprofessional collaboration enabled them to delegate diabetes education and monitoring and/or adjustment of medications to other health professionals and resulted in improved patient care. CONCLUSIONS: This study sheds new insight on the influence that being part of a primary care team has on physicians' practice. Specifically, supporting physicians' access to other health professionals in the primary care setting is perceived to facilitate interprofessional collaboration in the care of patients with T2DM and improve patient care.

Family physicians' perspectives on interprofessional teamwork: Findings from a qualitative study.

The aim of this study was to describe family physicians' perspectives of their role in the primary care team and factors that facilitate and hinder teamwork. A qualitative study was conducted employing individual interviews with 19 academic/community-based family physicians who were part of interprofessional primary care teams in Edmonton, Alberta, Canada. Professional responsibilities and roles of physicians within the team and the facilitators and barriers to teamwork were investigated. Interviews were audiotaped, transcribed and analysed for emerging themes. The study findings revealed that family physicians consistently perceived themselves as having the leadership role on in the primary care team. Facilitators of teamwork included: communication; trust and respect; defined roles/responsibilities of team members; co-location; task shifting to other health professionals; and appropriate payment mechanisms. Barriers to teamwork included: undefined roles/responsibilities; lack of space; frequent staff turnover; network boundaries; and a culture of power and control. The findings suggest that moving family physicians toward more integrative and interdependent functioning within the primary care team will require overcoming the culture of traditional professional roles, addressing facilitators and barriers to teamwork, and providing training in teamwork.

Motivations for learning of family medicine residents trained in competency-based education.

BACKGROUND AND OBJECTIVE: Family physicians regularly encounter clinical uncertainty and ambiguity and thus, are expected to engage in on-going learning to respond to changing needs of family practice. Using Achievement Goal Theory, the objective of this study was to examine motivations for learning of family medicine residents in a competency-based program. METHOD: This was a cross-sectional study, employing a survey methodology with family medicine residents at the mid-point of training at a Canadian university. Multivariate analyses of variance and covariance were used to examine residents' goal orientations (performance approach, mastery approach, performance avoidance, mastery avoidance) for the group as a whole and to test for the effects of residents' gender and program stream (urban/rural), respectively. RESULTS: A total of 52 (67%) residents completed the survey. Overall, residents scored highest on mastery approach and lowest on performance avoidance, thus, exhibiting adaptive motivations for learning. Male residents demonstrated higher levels of performance approach, performance avoidance, and mastery avoidance than female residents. No significant differences in goal orientations were found between urban and rural residents. CONCLUSIONS: Family medicine residents trained in the culture of competency-based education appear to be mastery approach oriented. This motivation orientation is critical in the dynamic practice of family medicine and is consistent with the life-long learning mandate of the medical profession.

Scope of practice of family medicine graduates who completed a rural versus urban program.

INTRODUCTION: In Canada, rural-based family medicine residency programs were established largely in response to a shortage of rural physicians and the perception that urban-based training programs were not meeting the needs of rural populations. Examinations of practice patterns of physicians trained in rural and urban programs are lacking. The purpose of this study was to compare the scope of practice of family medicine graduates who completed a rural versus an urban residency program, by practice location. METHODS: This was a cross-sectional, mail-out, questionnaire survey of 651 graduates who had completed the family medicine residency program at the University of Alberta or the University of Calgary, Alberta, Canada during 2006-2011. Rural program graduates lived and trained in regional settings and spent a considerable amount of time in smaller rural and remote communities for their clinical experience. The training of urban program graduates was primarily based in large urban settings and family medicine clinical experience was based in the community. Practice location (rural, urban) was classified by population size of the town/city at which physicians practiced. Scope of practice was ascertained through four domains of care: types of care, clinical procedures, practice settings and specific populations. Items within each domain were rated on a five-point scale (1='not part of practice', 5='element of core practice'). Mean rating scores for items in the domains of care were compared between urban and rural program graduates using ANOVA. RESULTS: A total of 307 (47.2%) graduates responded to the survey, of whom 173 were categorized as urban program graduates and 59 as rural program graduates. Overall, rural program graduates exhibited a broader scope of practice in providing postnatal care, intrapartum care/deliveries, palliative care, office-based and in-hospital clinical procedures, emergency care, in-hospital care, home visits, long-term care, and caring for rural and Aboriginal populations. Irrespective of program completed, those in a rural practice location had a broader scope of practice than those in urban practice. Urban and rural program graduates in rural locations tended to have a similar scope of practice. In urban locations, rural program graduates were more likely to include intrapartum care/deliveries as part of their clinical practice. Rural program graduates were more likely to practice in rural locations than urban program graduates. CONCLUSION: A combination of site of training (rural or urban program) and location of practice appear to work together to influence scope of practice of family physicians. A conceptual framework that summarizes the factors that have been reported to be associated with the scope of family practice is proposed.

Well-being of family medicine graduates.

OBJECTIVE: To determine family medicine graduates' professional and personal well-being, general health status, stress levels, coping strategies, and the degree to which they felt supported or isolated in professional life; and to compare findings by sex, practice location, and location of medical school (Canadian medical graduates [CMGs] vs international medical graduates [IMGs]). DESIGN: Retrospective, cross-sectional survey. SETTING: University of Alberta in Edmonton and the University of Calgary in Alberta. PARTICIPANTS: A total of 651 graduates who completed one of the family medicine residency programs during 2006 to 2011. MAIN OUTCOME MEASURES: Using a 5-point Likert scale, graduates rated their general health status, their personal and professional well-being, their level of stress, and the degree to which they felt supported or isolated in professional life. Respondents also identified important life events, their caregiving roles, and stress-coping strategies. RESULTS: Of 651 graduates, 307 (47.2%) responded to the survey. Personal and professional well-being and general health status were rated as very good or excellent by 72.0%, 76.6%, and 74.7% of graduates, respectively. Overall, 39.3% reported high or extremely high levels of stress, with CMGs exhibiting significantly higher stress levels than IMGs (P = .02). Stress scores were inversely related to personal and professional well-being and health status. In terms of coping strategies, a significantly greater proportion of female than male graduates reported talking to colleagues (76.5% vs 64.3%; P = .026) and seeking professional counseling (18.7% vs 6.1%; P = .002). Also, a significantly greater proportion of IMGs than CMGs (52.9% vs 32.5%; P = .003), as well as those in rural (35.8%) or urban (49.3%) practices than those in metropolitan locations (30.1%) (P = .03), turned to spiritual or religious practices for stress management. Of all respondents, 54.8% felt highly or extremely supported and 18.4% felt isolated in their professional lives. CONCLUSION: While family medicine graduates are primarily healthy and have a strong sense of personal and professional well-being, many experience high levels of stress. Coping strategies generally include social contact with family, friends, or colleagues and differ by sex, whether respondents are CMGs or IMGs, and practice location. Professional isolation appears to be prevalent in both rural and urban practice locations. Physician well-being programs should include a multifaceted approach to accommodate a range of physician preferences.