Characterizing the use of virtual care in primary care settings during the COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: In March 2020, Canada implemented restrictions to curb viral transmission of COVID-19, which resulted in abrupt disruptions to conventional (in-person) clinical care. To retain continuity of care the delivery of primary care services shifted to virtual care. This study examined the nature of virtual visits, characterizing the use and users of virtual care in primary care settings from March 14/20 to June 30/20 of the COVID-19 pandemic.  METHODS: Retrospective cohort study of primary care providers in Manitoba, Canada that participate in the Manitoba Primary Care Research Network (MaPCReN) and offered ≥ 1 virtual care visit between 03/14/20 and 06/30/20 representing 142,616 patients. Tariff codes from billing records determined the visit type (clinic visit, virtual care). Between 03/14/20, and 06/30/20, we assessed each visit for a follow-up visit between the same patient and provider for the same diagnosis code. Patient (sex, age, comorbidities, visit frequency, prescriptions) and provider (sex, age, clinic location, provider type, remuneration, country of graduation, return visit rate) characteristics describe the study population by visit type. Generalized estimating equation models describe factors associated with virtual care.  RESULTS: There were 146,372 visits provided by 154 primary care providers between 03/14/20 and 06/30/20, of which 33.6% were virtual care. Female patients (OR 1.16, CI 1.09-1.22), patients with ≥ 3 comorbidities (OR 1.71, CI 1.44-2.02), and patients with ≥ 10 prescriptions (OR 2.71, 2.2-1.53) had higher odds of receiving at least one virtual care visit compared to male patients, patients with no comorbidities and patients with no prescriptions. There was no significant difference between the number of follow-up visits that were provided as a clinic visit compared to a virtual care visit (8.7% vs. 5.8%) (p = 0.6496). CONCLUSION: Early in the pandemic restrictions, approximately one-third of visits were virtual. Virtual care was utilized by patients with more comorbidities and prescriptions, suggesting that patients with chronic disease requiring ongoing care utilized virtual care. Virtual care as a primary care visit type continues to evolve. Ongoing provision of virtual care can enhance quality, patient-centered care moving forward.

Multi-stakeholder validation of entrustable professional activities for a family medicine care of the elderly residency program: a focus group study.

Entrustable Professional Activities (EPAs) have become widely used within Competency-Based Medical Education (CBME) for the training and evaluation of residents. Little is known about the effectiveness of incorporating multiple stakeholder groups in the validation of EPAs. Here, we seek to validate an EPA framework developed for the University of Manitoba Care of the Elderly Enhanced Skills program using online focus groups consisting of five stakeholder groups. Participants were recruited to take part in one of five online focus groups, one for each stakeholder group (physician faculty, residents, non-physician healthcare professionals, administrators/managers, and patients). Each group met one time for 90 minutes over ZOOM®. The themes arising from stakeholder feedback suggest that successful EPAs must neither be too specific nor too expansive in scope, clearly delineate appropriate means of evaluation, and indicate specific clinical settings in which each EPA should be evaluated. Cross-cutting themes included requiring trainees to collaborate with other professionals when it would optimize patient care, and preparing trainees to advocate for their patients' health (Advocacy). The present study demonstrates that multi-stakeholder analysis yields diverse feedback that can help make EPAs more clear, easier to use in evaluation, and more socially accountable.

Twelve tips for adapting grand rounds for contemporary demands.

Grand rounds have evolved since inception in the early 1900s and subsequently, there has been a continual debate surrounding the best purpose for the time-honoured event. However, the purpose of grand rounds can be broadened to meet the needs of the medical community today, especially at a time where there is great distribution of medical practitioners and learners geographically and events such as COVID-19, which prevent the community from physically gathering. Using the evidence and lessons available from the literature we developed a grand rounds series with goals and objectives suited to our context. In this guide we provide twelve tips covering goal planning, logistics, presentation preparation and presentation delivery in order to illustrate how one could organize an informed grand rounds which is successful contextually.

Impact of COVID-19 on income, prevention attitudes, and access to healthcare among male clients in a Sexually Transmitted Infections clinic.

BACKGROUND: Mobility restrictions and overloaded health services during the COVID-19 pandemic compromised services dedicated to the prevention and care of HIV and other sexually transmitted infections (STI). In this study, we present client's responses to standardized questionnaires applied during the COVID-19 pandemic period as part of the strategy to measure impacts on social and sexual vulnerability, access to STI prevention services, and access to STI care. METHODS: The questionnaires included variables on sociodemographics, behavior, risk perception, prevention attitudes, barriers to service-based HIV rapid test, reasons for taking an HIV self-test, and access to health services for STI diagnosis and treatment. We explored demographic variables associated with income reduction, reduced access to HIV/STI testing/treatment and increased vulnerability to HIV/STI. RESULTS: 847 participants responded to the study questionnaire between May 2020 and January 2021. Most were young, cisgender male, and 63% self-reported as men who have sex with men. Income reductions were reported by 50%, with 30% reporting a decline over 50% of total income. An increase in heavy episodic drinking (>5 doses) was reported by 18%; 7% reported more sexual partners and 6% reported using condoms less often. Difficulties in obtaining HIV tests, tests for other STI and treatment for STI were reported by 5%, 6% and 6%, respectively. Lower schooling was significantly associated with income reduction (p = 0.004) and with reduced access to HIV/STI testing or STI treatment (p = 0.024); employment status was associated with income reduction (p < 0.001) and increased vulnerability to HIV/STI (p = 0.027). Having access to an expedite test result, avoiding physical attendance in health units during the pandemic, and undertaking the test with privacy with a trusted person were reported as motivators for HIV self-test. CONCLUSIONS: Our findings are relevant to promote service improvements tailored to subgroups more likely to struggle with detrimental effects during and after the COVID-19 pandemic.

A comparison of teaching opportunities for rural and urban family medicine residents.

CONTEXT: Medical schools of geographically large nations have expanded into rural areas to facilitate the development of a sustainable rural pipeline of physicians. Preceptor, or clinical teacher, recruitment at these sites has been an ongoing challenge. However, residents-as-teachers (RaT) curricula have not been modified to support the development of rural teachers. This study aimed to compare teaching opportunities between rural and urban family medicine residents and to identify mechanisms underlying potential differences. METHODS: Year-1 and Year-2 family medicine residents at seven Canadian institutions participated in a mixed-methods study utilising a quantitative survey and a qualitative interview. Rural and urban residents rated the quantity and types of teaching opportunities available during their training, from which a chi-squared analysis was completed. Volunteer respondents participated in a structured interview, from which a thematic analysis was performed. RESULTS: Rural family medicine residents had fewer opportunities to teach compared to their urban colleagues. This discrepancy was seen across multiple domains, including informal opportunities when on family medicine rotations, χ2 (4, n = 242) = 45.26, P < .000, Bonferroni's adjusted P < .000. Thematic analysis centred around determining factors influencing teaching opportunities and identified that the academic context, personal factors and programme factors were key dimensions. Within these dimensions, the number of medical students, a desire to be an educator and administrative support were cited as influences on teaching opportunities. CONCLUSIONS: The lack of teaching opportunities for rural trainees is attributable to a combination of practical and organisational factors revealed through thematic analysis. If rural graduates are not comfortable balancing the demands of service and teaching, this could compound the already prevalent issue of rural preceptor recruitment. It is essential to develop a rural-focused RaT curriculum to close this gap and produce competent educators who are ready to inspire generations of rural physicians.

Pushing for partnership: physician engagement and resistance in primary care renewal.

PURPOSE: Healthcare policymakers and managers struggle to engage private physicians, who tend to view themselves as independent of the system, in new models of primary care. The purpose of this paper is to examine this issue through a social identity lens. DESIGN/METHODOLOGY/APPROACH: Through in-depth interviews with 33 decision-makers and 31 fee-for-service family physicians, supplemented by document review and participant observation, the authors studied a Canadian province's early efforts to engage physicians in primary care renewal initiatives. FINDINGS: Recognizing that the existing physician-system relationship was generally distant, decision-makers invested effort in relationship-building. However, decision-makers' rhetoric, as well as the design of their flagship initiative, evinced an attempt to proceed directly from interpersonal relationship-building to the establishment of formal intergroup partnership, with no intervening phase of supporting physicians' group identity and empowering them to assume equal partnership. The invitation to partnership did not resonate with most physicians: many viewed it as an inauthentic offer from an out-group ("bureaucrats") with discordant values; others interpreted partnership as a mere transactional exchange. Such perceptions posed barriers to physician participation in renewal activities. PRACTICAL IMPLICATIONS: The pursuit of a premature degree of intergroup closeness can be counterproductive, heightening physician resistance. ORIGINALITY/VALUE: This study revealed that even a relatively subtle misalignment between a particular social identity management strategy and its intergroup context can have highly problematic ramifications. Findings advance the literature on social identity management and may facilitate the development of more effective engagement strategies.

Peer-assisted debriefing of multisource feedback: an exploratory qualitative study.

BACKGROUND: The Manitoba Physician Achievement Review (MPAR) is a 360-degree feedback assessment that physicians undergo every 7 years to retain licensure. Deliberate reflection on feedback has been demonstrated to encourage practice change. The MPAR Reflection Exercise (RE), a peer-assisted debriefing tool, was developed whereby the physician selects a peer with whom to review and reflect on feedback, committing to change. This qualitative study explores how physicians who had undergone the MPAR used the RE, what areas of change are identified and committed to, and what they perceived as the role of reflection in the MPAR process. METHODS: The MPAR RE was piloted out to a cohort of MPAR-reviewed physicians. Thematic analysis was conducted on completed exercises (n = 61). Semi-structured interviews were conducted with individuals (n = 6) who completed the MPAR RE until saturation was reached. RESULTS: Physicians reviewed feedback with a range of peers, including colleagues, staff, and spouses. Many physicians were surprised by feedback, both positive and negative, but interviewees found the RE useful in processing feedback. Areas where physicians committed to change were diverse, covering all CanMEDS roles. Most physicians identified themselves as being successful in implementing change, though time, habit, and structures were cited as barriers. CONCLUSIONS: Peer-assisted debriefing can assist reflection of multisource feedback. It is easy to implement, is not resource-intensive, and feedback implies that it is effective at promoting change. Participants, with the aid of peers, identified areas for change, developed approaches for change, and largely thought themselves successful at implementing changes. Areas of change included all seven CanMEDS roles.

Improving Family Medicine Residents' Written Communication Using a Self-assessment Process.

BACKGROUND: Although competency in written communication is a core skill, written communication is seldom the focus of formal instruction in medical education. The objective of this intervention was to implement a self-assessment strategy to assist learners in improving their letter writing skills and then to evaluate its feasibility, reliability and potential educational value. METHODS: Eight first-year family medicine residents from two teaching sites completing a six month family medicine rotation used a self-assessment process which included a self-study module and an assessment tool for letters. Each resident applied the self-assessment tool to eight to ten consecutive consult/referral request letters. Participants submitted initial and redrafted letters for independent rating. RESULTS: Analysis of the content, style and global ratings of the initial 77 draft letters showed multiple deficiencies in the content of their letters. It was confirmed that by using the self-assessment tool, residents were able to reliably assess the quality of their letters. Residents' assessments and those of the expert closely correlated (Pearson correlation 0.861, p < 0.0001). Over the course of the study the residents' overall performance improved and the difference in total scores between the initial drafts and the rewritten letters narrowed. CONCLUSION: A self-assessment process of written communication significantly improves the quality and completeness of routine consult/referral request letters.

Controlling quality in CME/CPD by measuring and illuminating bias.

INTRODUCTION: There has been a surge of interest in the area of bias in industry-supported continuing medical education/continuing professional development (CME/CPD) activities. In 2007, we published our first study on measuring bias in CME, demonstrating that our assessment tool was valid and reliable. In light of the increasing interest in this area, and building on our experience, we wanted to further understand the application of this tool in different environments. We invited other CME/CPD providers from multiple sites in Canada to participate in a second CME bias study. METHODS: A new steering committee was established with representatives from 5 academic CME/CPD offices nationally, the Royal College of Physicians and Surgeons, and the College of Family Physicians of Canada to outline the project in terms of review of the literature, refining items on the tool, updating the training guide for implementation, and establishing a resource Web site for reviewers. Training involved a train-the-trainer session with the event coordinators at each of the 5 participating centers via videoconferencing. RESULTS: The content reviews from the study showed moderate inter-rater reliability (ICC = 0.54), and the live reviews showed poor overall inter-rater reliability; however, one center achieved substantial inter-rater reliability (ICC = 0.68). DISCUSSION: The analysis from this study suggests that the tool can be used as a part of a multistage process to introduce quality control mechanisms to help raise standards for CME/CPD. It is imperative to develop a cost-effective standardized training protocol that can be implemented at all sites to maximize the reliability of the tool.