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.     

Interprofessional primary care in academic family medicine clinics: Implications for education and training

Objective

To explore the status and processes of interprofessional work environments and the implications for interprofessional education in a sample of family medicine teaching clinics.

Design

Focus group interviews using a purposive sampling procedure.

Setting

Four academic family medicine clinics in Alberta.

Participants

Seven family physicians, 9 registered nurses, 5 licensed practical nurses, 2 residents, 1 psychologist, 1 informatics specialist, 1 pharmacist, 1 dietitian, 1 nurse practitioner, 1 receptionist, and 1 respiratory therapist.

Methods

Assessment of clinic status and performance in relation to established principles of interprofessional work and education was explored using semistructured focus group interviews.

Main findings

Our data supported the D’Amour and Oandasan model of successful interprofessional collaborative practice in terms of the model’s main “factors” (ie, shared goals and vision, sense of belonging, governance, and the structuring of clinical care) and their constituent “elements.” It is reasonable to conclude that the extent to which these factors and elements are both present and positively oriented in academic clinic settings is an important contributory factor to the establishment of interprofessional collaborative practice in primary care. Using this model, 2 of the 4 clinics were rated as expressing substantial progress in relation to interprofessional work, while the other 2 clinics were rated as less successful on that dimension. None of the clinics was identified as having a clear and explicit focus on providing interprofessional education.

Conclusion

The key factor in relation to the implementation of interprofessional work in primary care appears to be the existence of clear and explicit leadership in that direction. Substantial scope exists for improvement in the organization, conduct, and promotion of interprofessional education for Canadian primary care.     

“My approach to this job is ... one person at a time”: Perceived discordance between population-level quality targets and patient-centred care

Objective

To understand the usefulness of audit and feedback among family physicians and examine the barriers to using it to improve quality of care.

Design

Qualitative study using in-depth interviews.

Setting

Family physicians across Ontario participating in audit and feedback initiatives describing the proportion of patients meeting quality targets for chronic disease.

Participants

Purposive sampling was conducted to ensure variation in sex, years of experience, and baseline performance for quality metrics. All participants used electronic medical records and worked in multidisciplinary primary care practices.

Methods

Semistructured interviews were conducted with family physicians. The interview guide and initial coding framework were adjusted iteratively in keeping with the constant comparative method. Sampling continued until saturation was reached. Interviews were analyzed using the framework approach.

Main findings

Participants reported that the feedback increased their awareness of gaps between ideal and actual performance. This resulted mainly in efforts to “try harder” patient by patient. Key barriers to acting upon feedback in a systematic manner included a perceived discordance between population-level quality targets and patient-centred care, as well as competing priorities at both the patient and organizational levels. Although all participants had electronic medical records, participants reported a lack of quality improvement infrastructure in their practices.

Conclusion

Family physicians were not highly motivated to achieve evidence-based population-level quality targets for diabetes; many competing organizational and clinical goals took priority. Additional human resources might be needed to translate data in feedback reports into systematic changes that could lead to sustained improvements in quality of care.     

Strategies for improved French-language health services: Perspectives of family physicians in northeastern Ontario

Objective

To identify strategies to improve the quality of health services for Francophone patients.

Design

A series of semistructured key informant interviews.

Setting

Northeastern Ontario.

Participants

A total of 18 physicians were interviewed. Ten physicians were interviewed in French, 7 physicians were women, and 10 physicians were located in urban communities.

Methods

Purposive and snowball sampling strategies were used to conduct a series of semistructured key informant interviews with family physicians practising in communities with a large Francophone population. Principles of grounded theory were applied, guided by a framework for patient-professional communication. Results were inductively derived following an iterative data collection–data analysis process and were analyzed using a detailed thematic approach.

Main findings

Respondents identified several strategies for providing high-quality French-language health services. Some were unique to non–French-speaking physicians (eg, using appropriate interpreter services), some were unique to French-speaking physicians (eg, using a flexible dialect), and some strategies were common to all physicians serving French populations (eg, hiring bilingual staff or having pamphlets and posters in both French and English).

Conclusion

Physicians interviewed for this study provided high-quality health care by attributing substantial importance to effective communication. While linguistic patient-to-physician concordance is ideal, it might not always be possible. Thus, conscious efforts to attenuate communication barriers are necessary, and several effective strategies exist.     

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.     

Approaches to diversity in family medicine: “I have always tried to be colour blind”

OBJECTIVE

To explore family physicians’ perceptions of and experiences with patient diversity, including differences in sex, race, ethnicity, social class, sexual orientation, and abilities or disabilities.

DESIGN

Semistructured, in-depth, qualitative interviews.SETTING Halifax metropolitan region, Nova Scotia.

PARTICIPANTS

Twenty-two family physicians who ranged in age (25 to 65 years) and in years of practice (< 5 to > 20). Participants included both sexes, members of racialized minority groups, and those who self-identified as gay, lesbian, or bisexual.

METHODS

Physicians were recruited through information letters distributed by mail and through professional networks. Interviews and field notes were recorded, transcribed verbatim, and coded using data analysis software. Weekly team discussions enhanced interpretation and analysis.

MAIN FINDINGS

Family physicians employed 5 main approaches to diversity: maintaining that differences do not matter, accommodating sociocultural differences, seeking to better understand differences, seeking to avoid discrimination, and challenging inequities. Quotes from interviews illustrate these themes.

CONCLUSION

Most approaches assume that both medicine (as a profession) and physicians are and should be socially and culturally neutral; some acknowledge that the sociocultural background of patients can raise tensions. Most participants in our study seek to treat patients as individuals in order to not stereotype, which hinders recognition of the ways in which sociocultural factors—both patients’ and physicians’—influence health and health care. Critical reflexivity demands that physicians understand social relations of power and where they fit within those relations.     

ColonCancerCheck Primary Care Invitation Pilot project: Family physician perceptions

Objective

To determine family physician perspectives regarding the acceptability and effectiveness of 2 interventions—a targeted, mailed invitation for screening to patients, and family physician audit-feedback reports—and on the colorectal cancer (CRC) screening program generally. This information will be used to guide program strategies for increasing screening uptake.

Design

Qualitative study.

Setting

Ontario.

Participants

Family physicians (n = 65).

Methods

Seven 1-hour focus groups were conducted with family physicians using teleconferencing and Web-based technologies. Responses were elicited regarding family physicians’ perspectives on the mailing of invitations to patients, the content and design of the audit-feedback reports, the effect of participation in the pilot project on daily practice, and overall CRC screening program function.

Main findings

Key themes included strong support for both interventions and for the CRC screening program generally. Moderate support was found for direct mailing of fecal occult blood testing (FOBT) kits. Participants identified potential pitfalls if interventions were implemented outside of patient enrolment model practices. Participants expressed relatively strong support for colonoscopy as a CRC screening test but relatively weak support for FOBT.

Conclusion

Although the proposed interventions to increase the uptake of CRC screening were highly endorsed, concerns about their applicability to non–patient enrolment model practices and the current lack of physician support for FOBT will need to be addressed to optimize intervention and program effectiveness. Our study is highly relevant to other public health programs planning organized CRC screening programs.     

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.     

Assessing the health care needs of women in rural British Columbia: Development and validation of a survey tool

Objective

To design reliable survey instruments to evaluate needs and expectations for provision of women''s health services in rural communities in British Columbia (BC). These tools will aim to plan programming for, and evaluate effectiveness of, a women''s health enhanced skills residency program at the University of British Columbia.

Design

A qualitative design that included administration of written surveys and on-site interviews in several rural communities.

Setting

Three communities participated in initial questionnaire and interview administration. A fourth community participated in the second interview iteration. Participating communities did not have obstetrician-gynecologists but did have hospitals capable of supporting outpatient specialized women''s health procedural care.

Participants

Community physicians, leaders of community groups serving women, and allied health providers, in Vancouver Island, Southeast Interior BC, and Northern BC.

Methods

Two preliminary questionnaires were developed to assess local specialized women''s health services based on the curriculum of the enhanced skills training program; one was designed for physicians and the other for women''s community group leaders and aboriginal health and community group leaders. Interview questions were designed to ensure the survey could be understood and to identify important areas of women''s health not included on the initial questionnaires. Results were analyzed using quantitative and qualitative methods, and a second draft of the questionnaires was developed for a second iteration of interviews.

Main findings

Clarity and comprehension of questionnaires were good; however, nonphysician participants answered that they were unsure on many questions pertaining to specific services. Topics identified as important and missing from questionnaires included violence and mental health. A second version of the questionnaires was shown to have addressed these concerns.

Conclusion

Through iterations of pilot testing, we created 2 validated survey instruments for implementation as a component of program evaluation. Testing in remote locations highlighted unique rural concerns, such that University of British Columbia health care professional training will now better serve BC community needs.     

Quebec breast cancer screening program: A study of the perceptions of physicians in Laval, Que

OBJECTIVE

To identify physicians’ perceptions of breast cancer prevention in order to generate strategies to increase women’s participation in the Quebec breast cancer screening program (QBCSP).

DESIGN

Qualitative study using archival data and in-depth interviews.

SETTING

Laval, Que, a suburban city north of Montreal.

PARTICIPANTS

Twenty family physicians and 1 gynecologist practising in Laval who had received at least 1 screening mammography report in 2004 or 2005.

METHODS

Archival data were obtained in order to refine our understanding of the QBCSP. In-depth individual interviews were conducted with participating physicians until data saturation was reached in order to determine physicians’ knowledge of, beliefs and attitudes about, and behaviour toward preventive breast cancer practices, as well as their suggestions for enhancing patient compliance. The interviews were recorded, transcribed, and coded, and the content was analyzed.

MAIN FINDINGS

Respondents indicated that the screening age groups, the age for beginning clinical breast examination, and the instructions to patients about breast self-examination should be harmonized. Letters to patients should be shortened, simplified, and endorsed by physicians. Screening mammography reports should include more details and be clearer about patient follow-up. The need for patients to sign authorization forms for transmission of information related to their participation in the QBCSP should be reinforced by their physicians. Following abnormal mammogram results, services and procedures should be simplified and delays in appointments decreased. Referral for “orphan patients” (ie, patients without family physicians) should be supervised by nurse practitioners, with physician consultations when needed.

CONCLUSION

This study provides a qualitative understanding of improvements or modifications needed in order to reach a screening mammography participation rate sufficient to reduce breast cancer mortality in women.     

Rural family medicine training site: Proposed framework

Objective

To develop a framework for a successful rural family medicine training program and to assess the potential for a rural family medicine residency training program using the Weyburn and Estevan areas of Saskatchewan as test sites.

Design

A mixed-method design was used; however, the focus of this article was on the qualitative data collected. Questions formulated for the semistructured interviews evolved from the literature.

Setting

Rural Saskatchewan.

Participants

Community physicians and representatives from the Sun Country Regional Health Authority, the Saskatchewan Ministry of Health, and the University of Saskatchewan.

Methods

The data were documented during the interviews using a laptop computer, and the responses were reviewed with participants at the end of their interviews to ensure accuracy. The qualitative data collected were analyzed using inductive thematic analysis.

Main findings

Through the analysis of the data several themes emerged related to implementing a rural family medicine residency training program. Key predictors of success were physical resources, physician champions, physician teachers, educational support, administrative support, and other specialist support. Barriers to the development of a rural family medicine training site were differing priorities, lack of human resources, and lack of physical resources.

Conclusion

A project of this magnitude requires many people at different levels collaborating to be successful.     

Primary health care models: Medical students�� knowledge and perceptions

Objective

To explore the knowledge and perceptions of fourth-year medical students regarding the new models of primary health care (PHC) and to ascertain whether that knowledge influenced their decisions to pursue careers in family medicine.

Design

Qualitative study using semistructured interviews.

Setting

The Schulich School of Medicine and Dentistry at The University of Western Ontario in London.

Participants

Fourth-year medical students graduating in 2009 who indicated family medicine as a possible career choice on their Canadian Residency Matching Service applications.

Methods

Eleven semistructured interviews were conducted between January and April of 2009. Data were analyzed using an iterative and interpretive approach. The analysis strategy of immersion and crystallization assisted in synthesizing the data to provide a comprehensive view of key themes and overarching concepts.

Main findings

Four key themes were identified: the level of students’ knowledge regarding PHC models varied; the knowledge was generally obtained from practical experiences rather than classroom learning; students could identify both advantages and disadvantages of working within the new PHC models; and although students regarded the new PHC models positively, these models did not influence their decisions to pursue careers in family medicine.

Conclusion

Knowledge of the new PHC models varies among fourth-year students, indicating a need for improved education strategies in the years before clinical training. Being able to identify advantages and disadvantages of the PHC models was not enough to influence participants’ choice of specialty. Educators and health care policy makers need to determine the best methods to promote and facilitate knowledge transfer about these PHC models.