Educating future physicians for Ontario: phase II.

In 1990, a collaborative project was launched to determine what the people of Ontario expect of their physicians and how the programs that prepare future physicians should be changed in response. The project, called Educating Future Physicians for Ontario (EFPO), brought together the five Ontario medical schools, the Council of Ontario Faculties of Medicine (COFM); a nonprofit, charitable organization, Associated Medical Services (AMS); and the Ontario Ministry of Health. The first phase ran for five years and was described in the November 1998 issue of Academic Medicine. After an external review, the project was continued for a second phase (EFPO II) for four more years until December 1998; that second phase is the topic of this article. EFPO II (1) focused more on residents' education; (2) emphasized four of the EFPO I-created physician roles in project activities; (3) maintained the province-wide, inter-institutional medical education framework of phase I, but fostered greater involvement of the seven sites (five medical schools and two regional health centers) in project activities; (4) stressed five project components (e.g., needs assessment and community partnerships) and worked for collaboration among components at all sites; (5) enhanced the original EFPO I Fellowship Program by adding residents and community fellows to the existing fellowships and by initiating leadership development activities, all of which bode well for the future leadership of medical education in Ontario. Students and residents played a vital role in EPFO II. Most of EFPO II's objectives were met, but the overall view of external reviewers was that the project was less successful than EFPO I. For example, the impact on clinical education, especially residency education, was less than anticipated. On the other hand, the project helped encourage the wide adoption of the eight physician roles that originated in EFPO I and advanced faculty development and assessment activities based on these roles. A third phase of EFPO concerning continuing medical education was planned, but support was not available. However, one of the funders will continue to support the successful fellowship and leadership program and the provincial education network for the next three years. Overall, the two phases of EFPO substantially modified medical education in Ontario to make it more responsive to evolving social needs.

Content in context: medical education and society's needs.

Many reports have emphasized the need to reform medical education to bring it into harmony with society's needs and expectations. Although much effort has been expended over several decades, many believe that reform initiatives have not successfully modified physicians' behaviors and attitudes. More recently, two major projects--Educating Future Physicians for Ontario and the Medical School Objectives Project--have identified physician roles and attributes necessary to meet societal needs. These efforts have provided a substantial framework upon which the content and conduct of a more relevant kind of medical education can be built. In order to implement real change, however, medical schools must (1) take the long view, making reform part of the entire continuum of medical education; (2) ensure that faculty physicians teach by example; (3) change student assessments to reflect new educational objectives; and (4) reallocate resources to support a changed curriculum.

Educating future physicians for Ontario.

In 1987, Ontario's physicians conducted a strike, ultimately not successful, over the issue of "extra billing." The fact that the Ontario public did not support this action reflected a major gap between the profession's view of itself and the public's view of the profession. In 1990, the province's five medical schools launched a collaborative project to determine more specifically what the people of Ontario expect of their physicians, and how the programs that prepare future physicians should be changed in response. The authors report on the first five years of that ongoing project. Consumer groups were asked to state their views concerning the current roles of physicians, future trends that would affect these roles, changes in roles they wished to see, and suggestions for changes in medical education. Methods used included focus groups, key informant interviews, an extensive literature review, and surveys, including a survey of health professionals. Concurrently, inter-university working groups prepared tools and strategies for strengthening faculty development, assessing student performance, and preparing future leadership for Ontario's medical education system. Eight specific physician roles were identified: medical expert, communicator, collaborator, health advocate, learner, manager ("gatekeeper"), scholar, and "physician as person." Educational strategies to help medical students learn to assume these eight roles were then incorporated into the curricula of the five participating medical schools. The authors conclude that the project shows that it is feasible to learn specifically what society expects of its physicians, to integrate this knowledge into the process of medical education reform, and to implement major curriculum changes through a collaborative, multi-institutional consortium within a single geopolitical jurisdiction.

Demand-side medical education: educating future physicians for Ontario.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province's evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project's five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.

The clinical teaching unit in transition.

The clinical teaching unit (CTU), a distinctively Canadian concept, has served Canadian academic medicine well over the past 30 years. Times have changed considerably since the concept was first defined by the Association of Canadian Medical Colleges in 1962. Many proposals and ideas of Evans, Chute and Morley in their description of the CTU, clinical education and the practice of medicine remain relevant today. The concept of learning by doing, under supervision, in a relatively controlled academic environment is still valid. However, we must either expand our concept of the traditional CTU to make it consistent with the contemporary broad practice of medicine or maintain the current model as complementary, but not necessarily central, to an expanded paradigm of clinical education.

Effective in-training evaluation.

Effective in-training evaluation can significantly enhance learning for both undergraduate and postgraduate medical students. The importance of ongoing assessment must be understood and supported by clinical teachers, and their involvement in effective evaluation requires time and effort. In-training evaluation can be both informal and formal and embrace a wide variety of methods. Self-evaluation by students should be emphasized as an important part of the in-training evaluation process. Clearly stated educational objectives, understood by both teachers and students, are essential. The use of constructive and supportive feedback adds considerably to clinical learning. Fair and forthright evaluation is of special importance when dealing with poor student performance.

Accreditation of specialty residency programmes in Canada.

The accreditation process gives assurance to a number of individuals and groups about the quality of approved programmes. It is based on principles that have evolved over time. The process of the Royal College of Physicians and Surgeons of Canada is based upon a set of nine explicitly stated standards, each amplified by a detailed interpretation. On-site surveys conducted at regular intervals by peers, with active involvement of the teachers and students being surveyed and using checks and balances with respect to information obtained and decisions made are major characteristics of the Canadian accreditation process.

Practice patterns and attitudes toward education among Canadian obstetricians and gynecologists.

A group of 1370 specialists in obstetrics and gynecology were surveyed for information about practice patterns, continuing medical education preferences, and their perception of the adequacy of their own residency training. The overall response rate was 65.7%. More than half were in solo practice, practiced in communities of over 250,000, had been in practice for more than 10 years, or had a full or part-time appointment with a Canadian medical school. A wide range of continuing medical education methods were used. Journals were ranked highest by 41%. It is disturbing that very few physicians (15%) indicated any involvement in practice audit. The quality of residency training was ranked low in a number of areas including genetic counseling, ultrasound, neonatology, intensive care, colposcopy, sexual dysfunction, marital counseling, and hysteroscopy. The survey highlights a number of areas that merit the attention of Canadian programs in postgraduate and continuing medical education in obstetrics and gynecology.