Residency research requirements and the CanMEDS-FM scholar role: Perspectives of residents and recent graduates

Objective

To explore the perspectives of family medicine residents and recent family medicine graduates on the research requirements and other CanMEDS scholar competencies in family practice residency training.

Design

Semistructured focus groups and individual interviews.

Setting

Family practice residency program at the University of British Columbia in Vancouver.

Participants

Convenience sample of 6 second-year family medicine residents and 6 family physicians who had graduated from the University of British Columbia family practice residency program within the previous 5 years.

Methods

Two focus groups with residents and individual interviews with each of the 6 recently graduated physicians. All interviews were audiotaped, transcribed, and analyzed for thematic content.

Main findings

Three themes emerged that captured key issues around research requirements in family practice training: 1) relating the scholar role to family practice, 2) realizing that scholarship is more than simply the creation or discovery of new knowledge, and 3) addressing barriers to integrating research into a clinical career.

Conclusion

Creation of new medical knowledge is just one aspect of the CanMEDS scholar role, and more attention should be paid to the other competencies, including teaching, enhancing professional activities through ongoing learning, critical appraisal of information, and learning how to better contribute to the dissemination, application, and translation of knowledge. Research is valued as important, but opinions still vary as to whether a formal research study should be required in residency. Completion of residency research projects is viewed as somewhat rewarding, but with an equivocal effect on future research intentions.     

Collaboration between family physicians and nurse clinicians: Opinions of graduates in family medicine

Objective

To determine whether graduating family physicians are exposed to collaboration between family physicians and nurse clinicians during their training, as well as their opinions about shared care between doctors and nurse clinicians in the delivery of patient care.

Design

Anonymous online survey.

Setting

Two French-Canadian university family medicine residency programs.

Participants

The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec.

Main outcome measures

The extent to which nurse clinicians in graduating family physicians’ training milieu were involved in preventive and curative patient care activities, and graduates’ opinions about nurse clinicians sharing care with physicians.

Results

Of 343 graduates, 186 (54.2%) participated in the survey. Although as residents in family medicine their exposure to shared care with nurse clinicians was somewhat limited, respondents indicated that they were generally quite open to the idea of sharing care with nurse clinicians. More than 70% of respondents agreed or strongly agreed that nurse clinicians could adjust, according to protocols of clinical guidelines, the treatment of patients with diabetes, hypertension, and asthma, as well as regulate medication for pain control in terminally ill patients. By contrast, respondents were less favourable to nurse clinicians adjusting the treatment of patients with depression. More than 80% of respondents agreed or strongly agreed that nurse clinicians could initiate treatment via a medical directive for routine hormonal contraception, acne, uncomplicated cystitis, and sexually transmitted infections. Respondents’ opinions on nurse clinicians initiating treatment for pharyngitis and otitis were more divided.

Conclusion

Graduating family physicians are quite open to collaborating with nurse clinicians. Although they have observed some collaboration between physicians and nurses, there are areas of shared clinical activities in which they would benefit from further exposure and training.     

Residents as teachers: Survey of Canadian family medicine residents

Objective

To examine Canadian family medicine residents’ perspectives surrounding teaching opportunities and mentorship in teaching.

Design

A 16-question online survey.

Setting

Canadian family medicine residency programs.

Participants

Between May and June 2011, all first- and second-year family medicine residents registered in 1 of the 17 Canadian residency programs as of September 2010 were invited to participate. A total of 568 of 2266 residents responded.

Main outcome measures

Demographic characteristics, teaching opportunities during residency, and resident perceptions about teaching.

Results

A total of 77.7% of family medicine residents indicated that they were either interested or highly interested in teaching as part of their future careers, and 78.9% of family medicine residents had had opportunities to teach in various settings. However, only 60.1% of respondents were aware of programs within residency intended to support residents as teachers, and 33.0% of residents had been observed during teaching encounters.

Conclusion

It appears that most Canadian family medicine residents have the opportunity to teach during their residency training. Many are interested in integrating teaching as part of their future career goals. Family medicine residencies should strongly consider programs to support and further develop resident teaching skills.     

Practice patterns of graduates of a CCFP(EM) residency program: A survey

Objective

To determine the practice settings of graduates of a residency program that leads to a Certificate of Special Competence in Emergency Medicine (CCFP[EM]).

Design

Web-based survey using standard Dillman methodology.

Setting

Canada.

Participants

All graduates of the CCFP(EM) residency training program at the University of Toronto (U of T) in Ontario between 1982 and 2009.

Main outcome measures

Practice type and location, job satisfaction, and nonclinical EM activities of graduates of a CCFP(EM) residency program.

Results

Of 146 graduates surveyed, 88 responded (response rate of 60.3%). All of the respondents indicated that they had practised EM at some point after completing the CCFP(EM) program at U of T. At survey completion, 76.7% were practising EM. Of the EM-practising cohort, 93.9% worked in urban or suburban hospitals as opposed to rural settings. Those practising EM expressed high levels of job satisfaction, with 83.3% reporting a score of 8 or higher on a 10-point satisfaction scale. Most (57.0%) of the graduates of the CCFP(EM) residency program at U of T had participated in leadership activities in EM on local, provincial, or national levels.

Conclusion

Most graduates of the CCFP(EM) residency program continue to practise EM, and most of them practise in urban and suburban environments. The low attrition rate of CCFP(EM) graduates should be regarded as a success of the CCFP(EM) program, and the geographic distribution of all physicians, including EM providers, warrants further study to help plan future physician resources in Canada.     

Colorectal cancer screening practices in Saskatchewan: Survey of family physicians

Objective

To evaluate current colorectal cancer (CRC) screening practices in Saskatchewan and identify barriers to screening with the goal of improving current practice.

Design

Survey of family physicians.

Setting

Saskatchewan.

Participants

A total of 773 family physicians were surveyed.

Main outcome measures

Demographic characteristics, individual screening practices, and perceived barriers to screening.

Results

The response rate to the survey was 44.5%. When asked what method they used for fecal occult blood testing, almost 40% of respondents were either unsure or did not answer the question. Of those who did respond, 35.8% employed hemoccult testing following digital rectal examination, a practice not recommended for CRC screening. Screening guidelines for average-risk patients were generally well adhered to, with 79.9% of respondents recommending screening beginning at age 50. For screening patients at increased risk of CRC owing to family history, only 64.2% of respondents began screening 10 years before the age of the index patient at diagnosis. Physicians who were more likely to follow guidelines were female, in practice fewer than 10 years, trained in Canada, and practising in urban areas. More than 90% of family physicians agreed that a standard provincewide screening program would be beneficial.

Conclusion

We have identified considerable knowledge gaps with regard to CRC screening. There is confusion about which fecal occult blood tests are recommended for screening. Also, screening guidelines for patients with a family history of CRC are poorly understood. These findings suggest that better physician education about CRC screening is required. Introduction of a provincewide screening program should improve overall screening success.     

Assessment of communication skills in family medicine

Objective

To assess the communication and interviewing skills of incoming residents and provide formative feedback to residents early in their training.

Design

New residents completed a 15-minute objective structured clinical examination (OSCE) assessing communication skills and a 12-question, self-administered content quiz at the start of their residency. Each resident was directly observed by a family physician in the OSCE and provided with 15 minutes of structured feedback, with an opportunity for questions and discussion. The entire process remained private and did not affect summative evaluations.

Setting

Family medicine residency training program at the University of Alberta in Edmonton.

Participants

First-year family medicine residents.

Main outcome measures

Residents’ scores on the OSCE and the content quiz; residents’ rating of the usefulness of the assessment and the likelihood it would lead to practice change.

Results

A total of 61 residents (93.8%) completed the skills assessment (50 Canadian graduates, 11 international graduates). The mean score for the content quiz was 20.6 out of a total possible score of 24. Resident scores ranged from 8 to 24. The mean score on the OSCE practice interview was 21.1 out of 30, with a range of 13 to 29. Learner feedback indicated that the skills assessment was useful (4.68 out of 6) and would lead to a change in practice (4.43 out of 6).

Conclusion

The introductory communication OSCE and quiz offer new residents an opportunity to gauge their baseline skill level, become aware of program expectations early in their training, and garner specific suggestions in a nonthreatening environment. This tailored approach helps orient residents while taking into account their previous experiences.     

Protected block time for teaching and learning in a postgraduate family practice residency program

Objective

To explore the elements necessary for a high-quality educational experience in a family practice residency program with respect to scheduling, learning environment, and approaches to teaching and learning.

Design

An interpretative, qualitative study using a generative-inquiry approach.

Setting

The Nanaimo Site of the University of British Columbia Family Practice Residency Program.

Participants

Fifteen physician instructors and 16 first- and second-year residents.

Methods

Data were gathered from 2 qualitative focus group interviews with residents; 2 qualitative focus group interviews with physician instructors; and structured and semistructured observation of 2 in-class seminars, with a focus on residents’ engagement with the class. Results were analyzed and categorized into themes independently and collectively by the researchers.

Main findings

Protected block time for teaching and learning at the Nanaimo Site has been effective in fostering a learning environment that supports collegial relationships and in-depth instruction. Residents and physician instructors benefit from the week-long academic schedule and the opportunity to teach and learn collaboratively. Participants specifically value the connections among learning environment, collegiality, relationships, reflective learning, and the teaching and learning process.

Conclusion

These findings suggest that strategic planning and scheduling of teaching and learning sessions in residency programs are important to promoting a comprehensive educational experience.     

Family physicians providing regular care to residents in Ontario long-term care homes: Characteristics and practice patterns

Objective

To describe the characteristics and practice patterns of family physicians who regularly treat long-term care (LTC) residents in order to inform quality improvement strategies.

Design

Cross-sectional study involving a 2005 province-wide census of LTC residents’ charts linked to additional health care administrative databases.

Setting

All LTC homes in Ontario.

Participants

Residents aged 66 years and older (n = 50375) and the family physicians (n = 1190) most responsible for their care.

Main outcome measures

Distribution of LTC residents across family physicians, and physician demographic characteristics and practice patterns.

Results

The distribution of residents across physicians was highly skewed (median 27 residents, mean 42.5 residents). The care of 90.4% of residents was accounted for by 628 (52.8%) identified physicians. Family physicians practising in LTC facilities were more likely to be older (mean age 52.4 years vs 48.2 years, P < .001) and male (82.4% vs 61.5%, P < .001) than other family physicians. Urban physicians who provided care to LTC residents had bigger LTC practices than rural LTC physicians did (median 50 residents vs median 12 residents).

Conclusion

About 600 family physicians are responsible for the regular care of more than 90% of LTC residents in Ontario and quality improvement efforts could be aimed at this relatively small group of physicians. Half of the urban physicians who practise in LTC homes are responsible for 50 or more LTC residents. This might represent a key part of their overall practice.     

Practice and payment preferences of newly practising family physicians in British Columbia

Objective

To examine the remuneration model preferences of newly practising family physicians.

Design

Mixed-methods study comprising a cross-sectional, Web-based survey, as well as qualitative content analysis of answers to open-ended questions.

Setting

British Columbia.

Participants

University of British Columbia family practice residents who graduated between 2000 and 2009.

Main outcome measures

Preferred remuneration models of newly practising physicians.

Results

The survey response rate was 31% (133 of 430). Of respondents, 71% (93 of 132) preferred non–fee-for-service practice models and 86% (110 of 132) identified the payment model as very or somewhat important in their choice of future practice. Three principal themes were identified from content analysis of respondents’ open-ended comments: frustrations with fee-for-service billing, which encompassed issues related to aggravations with “the business side of things” and was seen as impeding “the freedom to focus on medicine”; quality of patient care, which embraced the importance of a payment model that supported “comprehensive patient care” and “quality rather than quantity”; and freedom to choose, which supported the plurality of practice preferences among providers who strived to provide quality care for patients, “whatever model you happen to be working in.”

Conclusion

Newly practising physicians in British Columbia preferred alternatives to fee-for-service payment models, which were perceived as contributing to fewer frustrations with billing systems, improved quality of work life, and better quality of patient care.     

Debiasing the hidden curriculum: academic equality among medical specialties

Objective

To compare the academic performance of students who entered family medicine residency programs with that of students who entered other disciplines and discern whether or not family physicians are as academically talented as their colleagues in other specialties.

Design

Retrospective quantitative study.

Setting

University of Calgary in Alberta.

Participants

Three graduating classes of students (2004 to 2006) from the University of Calgary medical school.

Main outcome measures

Student performance on various undergraduate certifying examinations in years 1, 2, and 3, along with third-year in-training evaluation reports and total score on the Medical Council of Canada Qualifying Examination Part I.

Results

Complete data were available for 99% of graduates (N = 295). In the analysis, residency program (family medicine [n = 96] versus non–family medicine [n = 199]) served as the independent variable. Using a 1-way multivariate ANOVA (analysis of variance), no significant difference among any of the mean performance scores was observed (F₅₂₈₉ = 1.73, P > .05). Students who entered family medicine were also well represented within the top 10 rankings of the various performance measures.

Conclusion

The academic performance of students who pursued careers in family medicine did not differ from that of students who chose other specialties. Unfounded negativity toward family medicine has important societal implications, especially at a time when the gap between the number of family physicians and patients seeking primary care services appears to be widening.     

Pharmacists teaching in family medicine residency programs: National survey

Objective

To determine the percentage of family medicine residency programs that have pharmacists directly involved in teaching residents, the types and extent of teaching provided by pharmacists in family medicine residency programs, and the primary source of funding for the pharmacists.

Design

Web-based survey.

Setting

One hundred fifty-eight resident training sites within the 17 family medicine residency programs in Canada.

Participants

One hundred residency program directors who were responsible for overseeing the training sites within the residency programs were contacted to determine the percentage of training sites in which pharmacists were directly involved in teaching. Pharmacists who were identified by the residency directors were invited to participate in the Web-based survey.

Main outcome measures

The percentage of training sites for family medicine residency that have pharmacists directly involved in teaching residents. The types and the extent of teaching performed by the pharmacists who teach in the residency programs. The primary source of funding that supports the pharmacists’ salaries.

Results

More than a quarter (25.3%) of family medicine residency training sites include direct involvement of pharmacist teachers. Pharmacist teachers reported that they spend a substantial amount of their time teaching residents using a range of teaching modalities and topics, but have no formal pharmacotherapy curriculums. Nearly a quarter (22.6%) of the pharmacists reported that their salaries were primarily funded by the residency programs.

Conclusion

Pharmacists have a role in training family medicine residents. This is a good opportunity for family medicine residents to learn about issues related to pharmacotherapy; however, the role of pharmacists as educators might be optimized if standardized teaching methods, curriculums, and evaluation plans were in place.     

Shifting into third gear: Current options and controversies in third-year postgraduate family medicine programs in Canada

Objective

To summarize current options for postgraduate third-year programs in family medicine in Canada and compile current controversies about the expanding number of programs available and the trend toward subspecialization in family medicine.

Design

A literature search was conducted by the Regina Qu’Appelle Health Region Library research staff for Canadian family medicine fellowships and residency programs using MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature from the beginning of 2005 to September 1, 2011. All available websites for programs offering third-year options were reviewed.

Setting

Canadian family medicine residency programs.

Methods

A list of current third-year residency programs was generated from the Canadian Post-MD Education Registry. In addition, the current Canadian Resident Matching Service website was reviewed, along with every program-specific website, for current third-year programs offered.

Main findings

More than 30 different options for third-year residency programs are available, including a number of community-influenced and resident-directed enhanced-skills programs. In 2010 to 2011 there were 237 postgraduate third-year family medicine residents compared with 128 in 2010 to 2011, an increase of 109 positions.

Conclusion

Controversies over the benefits to the patient population, the practice patterns of third-year residency graduates, and the influence of a subspecialty trend against a stated goal of comprehensive family medicine continue to exist, while the number of available third-year residency options continues to expand.     

Effect of colleague and coworker abuse on family physicians in Canada

Objective

To assess the effects of physician-colleague and coworker abuse on family physicians in Canada.

Design

A mixed-methods, bilingual study that included surveys and telephone interviews.

Setting

Canada.

Participants

Family physicians in active practice who were members of the College of Family Physicians of Canada in 2009.

Methods

Surveys were mailed to a random sample of family physicians (N = 3802), and 37 family physicians who had been abused in the past year participated in telephone interviews.

Main findings

A total of 770 surveys (20%) were completed. A small number of respondents reported having been subjected to abuse by physician colleagues (9%) or coworkers (6%) in the previous month. Many of the respondents reported that the same physician colleagues or coworkers were repeat abusers. More than three-quarters (77%) of the physician-colleague abusers were men, whereas more than three-quarters (77%) of the other coworker abusers were women. Interviewed family physicians described feeling humiliated and unappreciated, and developed symptoms of anxiety or depression. As a result of the abuse, some family physicians terminated their employment or refused to work in certain environments. The most striking effect of this abuse was that respondents reported losing confidence in their professional abilities and skills.

Conclusion

Although only a small number of family physicians experience abuse by physician colleagues and other coworkers, the effects can be considerable. Victims reported a loss of confidence in their clinical abilities and some subsequently were faced with mental health issues.