Family physicians and health advocacy: Is it really a difficult fit?

OBJECTIVE: To examine whether family medicine residents and faculty members appreciate the full spectrum of health advocacy as described in articles published in Canadian Family Physician in 2016 and to identify the perceived challenges and enablers of advocating across the entire spectrum. DESIGN: Analysis of a subset of data from a qualitative study using semistructured interviews and focus groups. SETTING: University of Toronto in Ontario. PARTICIPANTS: A total of 9 family medicine faculty members and 6 family medicine residents. METHODS: A subset of transcripts from a 2015 qualitative study that explored family medicine and psychiatry residents' and faculty members' understanding of the CanMEDS-Family Medicine health advocate role were reviewed, guided by interpretive descriptive methodology. MAIN FINDINGS: Results indicated that family medicine physicians and residents were able to identify the full spectrum of advocacy described in the Canadian Family Physician articles and that they valued the role. Further, there was widespread agreement that being a health advocate was linked with their identities as health professionals. The time it takes to be a health advocate was seen as a barrier to being effective in the role, and the work was seen as extremely challenging owing to system constraints. Participants also described a gap in training relating to advocacy at the system level as a challenge. CONCLUSION: Team-based care was seen as one of the most important enablers for becoming involved in the full spectrum of advocacy, as was time for personal reflection.

Knowledge and Practices of Family and Emergency Physicians in Managing Nontraumatic Dental Conditions: A Case-based Survey.

INTRODUCTION: Physicians are often patients' first point of contact for management of nontraumatic dental conditions (NTDCs). This study's aim was to evaluate the knowledge and practices of Ontario physicians in managing NTDCs, with a specific focus on antibiotic usage. METHODS: A Web-based survey featured 4 NTDC clinical scenarios: irreversible pulpitis, localized acute apical abscess with or without systemic involvement, and chronic apical abscess. The survey link was distributed to active Ontario family and emergency physicians. The sample group was asked questions about their management of and experience with NTDCs, and demographic and practice characteristics were collected. Descriptive and multivariate logistic regression analyses were undertaken (P ≤ .05). RESULTS: Sampled Ontario physicians tend to manage NTDCs in a manner that is not consistent with evidence-based care. For irreversible pulpitis and for localized acute apical abscess with or without systemic involvement, most physicians would prescribe an antibiotic (57.4%, 84.8%, and 96.3%, respectively), and 23.5% would prescribe an antibiotic for chronic apical abscess. Approximately half the sample (52.9%) felt discomfort in managing NTDCs, and 85.3% felt they were inadequately trained to manage NTDCs. CONCLUSION: Areas that present opportunities for improvement in the physician management of NTDCs were identified, including the incorporation of further NTDC training in medical curricula and continuing medical education courses, and development and dissemination of guidelines for physicians in managing NTDCs.

Understanding health advocacy in family medicine and psychiatry curricula and practice: A qualitative study.

BACKGROUND: We explored understanding and experiences of health advocacy among psychiatry and family medicine residents and faculty and the implications for clinical care and teaching through the lens of relationship-centred care. METHODS: This qualitative study was conducted in the psychiatry and family medicine departments at a large urban university. We interviewed 19 faculty members and conducted two focus groups with 18 residents. Semi-structured questions explored the relational meaning of health advocacy, how residents and faculty learned about the role and ethical considerations involved in incorporating advocacy work into clinical practice within a relationship-centred care framework. RESULTS: Four themes emerged from the interviews and focus groups: 1) health advocacy as an extension of the relationship to self; 2) health advocacy and professional boundaries in the physician-patient relationship; 3) health advocacy within a team-based approach; and 4) health advocacy and the physician-community/organization relationship. Participants described implications for practice of the challenges of health advocacy, including perceived institutional risks, professional boundaries and the appropriation of patient voice. CONCLUSIONS: Our study provides insights into the relational complexities of the health advocate role in residency curriculum and clinical practice. All participants described health advocacy as a broad spectrum of actions that are guided by relationships among patients, health care professionals and communities. Our analysis revealed that some challenges that participants identified with a health advocacy role could be addressed by anchoring the role within a specific theoretical framework. This would better enable us to create a culture of advocacy in the training and development of physicians.

Does clinical exposure matter? Pilot assessment of patient visits in an urban family medicine residency program.

OBJECTIVE: To determine the number of patient visits, patient demographic information, and diagnoses in an urban ambulatory care setting in a family medicine residency program, and assess the correlation between the number of patient visits and residents' in-training examination (ITE) scores. DESIGN: Retrospective analysis of data from resident practice profiles, electronic medical records, and residents' final ITE scores. SETTING: Family medicine teaching unit in a community hospital in Barrie, Ont. PARTICIPANTS: Practice profile data were from family medicine residents enrolled in the program from July 1, 2013, to June 30, 2014, and electronic medical record and ITE data were from those enrolled in the program from July 1, 2010, to June 30, 2015. MAIN OUTCOME MEASURES: Number of patient visits, patient characteristics (eg, sex, age), priority topics addressed in clinic, resident characteristics (eg, age, sex, level of residency), and residents' final ITE scores. RESULTS: Between July 1, 2013, and June 30, 2014, there were 11 115 patient visits. First-year residents had a mean of 5.48 patient visits per clinic, and second-year residents had a mean of 5.98 patient visits per clinic. A Pearson correlation coefficient of 0.68 was found to exist between the number of patients seen and the final ITE scores, with a 10.5% difference in mean score between residents who had 1251 or more visits and those who had 1150 or fewer visits. Three diagnoses (ie, epistaxis, meningitis, and neck pain) deemed important for Certification by the College of Family Physicians of Canada were not seen by any of the residents in clinic. CONCLUSION: There is a moderate correlation between the number of patients seen by residents in ambulatory care and ITE scores in family medicine. It is important to assess patients' demographic information and diagnoses made in resident practices to ensure an adequate clinical experience.

FM-MAP: A Novel In-Training Examination Predicts Success on Family Medicine Certification Examination.

BACKGROUND AND OBJECTIVES: The objective of our study was to assess the correlation between a locally developed In-Training Examination (ITE) and the certification examination in family medicine in Canada. METHODS: The ITE was taken twice yearly, which corresponded for most residents to the fifth, ninth, 17th, and 21st month of training. The results for the ITE were correlated to the CFPC certification examination taken in the 23rd month of residency. RESULTS: The scores on each of the four iterations of the ITE correlated moderately well with performance relating to problem solving skills and knowledge on the certification examination. The ITE showed a trend to an increased correlation with duration in the training program with a Spearman correlation coefficient increasing from 0.45 on the first test to 0.54 on the fourth test. The correlation of the ITE with performance on the component assessing the doctor- patient relationship on the certification examination was poor (r=0.26 on the last test). CONCLUSION: Our in-training examination is a useful predictor of performance in problem solving and knowledge domains of the family medicine expert role on the certification examination.

Adult health checkup: Update on the Preventive Care Checklist Form©.

OBJECTIVE: To describe updates to the Preventive Care Checklist Form© to help family physicians stay up to date with current preventive health care recommendations. QUALITY OF EVIDENCE: The Ovid MEDLINE database was searched using specified key words and other terms relevant to the periodic health examination. Secondary sources, such as the Canadian Task Force on Preventive Health Care, the Public Health Agency of Canada, the Trip database, and the Canadian Medical Association Infobase, were also searched. Recommendations for preventive health care for average-risk adults were reviewed. Strong and weak recommendations are presented on the form in bold and italic text, respectively. MAIN MESSAGE: Updates were made to the form based on the Canadian Task Force on Preventive Health Care recommendations on screening for obesity (2015), cervical cancer (2013), depression (2013), osteoporosis (2013), hypertension (2012), diabetes (2012, 2013), and breast cancer (2011). Updates were made based on recommendations from other Canadian organizations on screening for HIV (2013), screening for sexually transmitted infections (2013), immunizations (2012 to 2014), screening for dyslipidemia (2012), fertility counseling for women (2011, 2012), and screening for colorectal cancer (2010). Some previous recommendations were removed and others lacking evidence were not included. CONCLUSION: The Preventive Care Checklist Form has been updated with current recommendations to enable family physicians to provide comprehensive, evidence-based care to patients during periodic health examinations.

Objective Evaluation of Otoscopy Skills Among Family and Community Medicine, Pediatric, and Otolaryngology Residents.

INTRODUCTION: The objective of this study is to evaluate and compare the perceived need for otolaryngology training and otoscopy diagnostic skills in primary care (Family and Community Medicine, Pediatric Medicine), and Otolaryngology Head and Neck Surgery (OTO-HNS) postgraduate trainees. Participant otoscopy skills were evaluated using the OtoSim simulator. METHODS: Family and Community Medicine, Pediatric, and OTO-HNS residents were recruited. Each resident participated in 3 separate otoscopy training and assessment sessions. The ability to correctly identify middle ear pathology was objectively evaluated using OtoSim™. Pretest, posttest, and 3-month retention test results were compared among residents in a paired comparison paradigm. Survey data assessing exposure to OTO-HNS during undergraduate and postgraduate training were also collected. RESULTS: A total of 57 residents participated in the study. All residents reported limited exposure to OTO-HNS during undergraduate medical training. Primary care trainees performed poorly on pretest assessments (30% ± 7.8%; 95% CI). Significant improvement in diagnostic accuracy was demonstrated following a single 1-hour teaching session (30%-62%; p < 0.001). Primary care residents demonstrated a significant decrease in diagnostic accuracy at a 3-month follow-up assessment (62%-52%, p < 0.001). Self-perceived comfort with otology was poorly correlated to pretest performance among primary care trainees (r = 0.26) and showed a stronger positive correlation among OTO-HNS trainees (r = 0.56). CONCLUSIONS: A single teaching session with an otoscopy simulator significantly improved diagnostic accuracy in primary care and OTO-HNS trainees. Improved performance is susceptible to deterioration at 3 months if acquired skills are not frequently used. Self-perceived comfort with otology may not be an accurate predictor of otoscopic diagnostic skill.

Herpes zoster as a marker of underlying malignancy.

BACKGROUND: Both herpes zoster and malignancy are associated with immunosuppression. However, the association between herpes zoster and the subsequent diagnosis of malignancy is unclear. We undertook this study to assess whether a diagnosis of herpes zoster is a risk factor for subsequent malignancy. METHODS: For this matched retrospective cohort study, a physician billing database was used to identify individuals 18 years of age or older with a diagnosis of herpes zoster and no prior diagnosis of cancer or HIV infection. Individuals with a herpes zoster diagnosis were matched one-to-one to individuals without a herpes zoster diagnosis, and both groups were examined for up to 5 years for diagnosis of cancer. RESULTS: A total of 542,575 individuals with a diagnosis of herpes zoster were identified. Compared with matched controls, these patients were more likely (p < 0.001) to have a history of myocardial infarction, asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension. The incidence of cancer was significantly greater among individuals with herpes zoster than among those without herpes zoster, for both men and women and across all time intervals studied (up to 5 years). The greatest adjusted hazard ratio was seen 180 days after a herpes zoster diagnosis (1.19, 95% confidence interval 1.12-1.25); the hazard ratio decreased as the time from herpes zoster diagnosis increased. Lymphoma was the type of cancer with the greatest relative increase in incidence following diagnosis of herpes zoster. INTERPRETATION: There is a risk of malignancy following an episode of herpes zoster in both men and women and in all age groups 18 years and over. The risk is greatest during the first 180 days following the diagnosis of herpes zoster.

Curriculum to enhance pharmacotherapeutic knowledge in family medicine: interprofessional coteaching and web-based learning.

PROBLEM ADDRESSED: Prescribing is an essential skill for physicians. Despite the fact that prescribing habits are still developing in residency, formal pharmacotherapy curricula are not commonplace in postgraduate programs. OBJECTIVE OF PROGRAM: To teach first-year and second-year family medicine residents a systematic prescribing process using a medication prescribing framework, which could be replicated and distributed. PROGRAM DESCRIPTION: A hybrid model of Web-based (www.rationalprescribing.com) and in-class seminar learning was used. Web-based modules, consisting of foundational pharmacotherapeutic content, were each followed by an in-class session, which involved applying content to case studies. A physician and a pharmacist were coteachers and they used simulated cases to enhance application of pharmacotherapeutic content and modeled interprofessional collaboration. CONCLUSION: This systematic approach to prescribing was well received by family medicine residents. It might be important to introduce the process in the undergraduate curriculum-when learners are building their therapeutic foundational knowledge. Incorporating formal pharmacotherapeutic curriculum into residency teaching is challenging and requires further study to identify potential effects on prescribing habits.

Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey.

BACKGROUND: Chronic kidney disease is an important risk factor for death and cardiovascular-related morbidity, but estimates to date of its prevalence in Canada have generally been extrapolated from the prevalence of end-stage renal disease. We used direct measures of kidney function collected from a nationally representative survey population to estimate the prevalence of chronic kidney disease among Canadian adults. METHODS: We examined data for 3689 adult participants of cycle 1 of the Canadian Health Measures Survey (2007-2009) for the presence of chronic kidney disease. We also calculated the age-standardized prevalence of cardiovascular risk factors by chronic kidney disease group. We cross-tabulated the estimated glomerular filtration rate (eGFR) with albuminuria status. RESULTS: The prevalence of chronic kidney disease during the period 2007-2009 was 12.5%, representing about 3 million Canadian adults. The estimated prevalence of stage 3-5 disease was 3.1% (0.73 million adults) and albuminuria 10.3% (2.4 million adults). The prevalence of diabetes, hypertension and hypertriglyceridemia were all significantly higher among adults with chronic kidney disease than among those without it. The prevalence of albuminuria was high, even among those whose eGFR was 90 mL/min per 1.73 m(2) or greater (10.1%) and those without diabetes or hypertension (9.3%). Awareness of kidney dysfunction among adults with stage 3-5 chronic kidney disease was low (12.0%). INTERPRETATION: The prevalence of kidney dysfunction was substantial in the survey population, including individuals without hypertension or diabetes, conditions most likely to prompt screening for kidney dysfunction. These findings highlight the potential for missed opportunities for early intervention and secondary prevention of chronic kidney disease.

Competency-based education in family medicine.

BACKGROUND: As a way of demonstrating an objective assessment of trainee competence, the College of Family Physicians of Canada has recently approved a competency-based framework known as CanMEDS-FM. All training programs in family medicine in Canada will be required to demonstrate the development of curriculum and evaluation methods based on the roles defined by the framework. AIM: This article describes the rationale and the approach used to develop a competency-based education curriculum in the postgraduate family medicine program at the University of Toronto. METHOD: The authors describe a systematic approach to curriculum development which includes the formation of a central steering committee, content development by faculty experts, mapping of curriculum to an accreditation framework, and a faculty consensus exercise. We discuss challenges to development and implementation of a competency-based framework as well as areas that require further work and development. CONCLUSIONS: The competency-based curriculum is both a new method of learning for residents and, a new method of teaching for faculty. While there are many potential benefits and challenges, this article focuses on the model's utility in terms of flexible learner-centered educational design, as well as its ability to identify learners' strengths and needs.

Identifying public health competencies relevant to family medicine.

Public health situations faced by family physicians and other primary care practitioners, such as severe acute respiratory syndrome (SARS) and more recently H1N1, have resulted in an increased interest to identify the public health competencies relevant to family medicine. At present there is no agreed-on set of public health competencies delineating the knowledge and skills that family physicians should possess to effectively face diverse public health challenges. Using a multi-staged, iterative process that included a detailed literature review, the authors developed a set of public health competencies relevant to primary care, identifying competencies relevant across four levels, from "post-MD" to "enhanced." Feedback from family medicine and public health educator-practitioners regarding the set of proposed "essential" competencies indicated the need for a more limited, feasible set of "priority" areas to be highlighted during residency training. This focused set of public health competencies has begun to guide relevant components of the University of Toronto's Family Medicine Residency Program curriculum, including academic half-days; clinical experiences, especially identifying "teachable moments" during patient encounters; resident academic projects; and elective public health agency placements. These competencies will also be used to guide the development of a family medicine-public health primer and faculty development sessions to support family medicine faculty facilitating residents to achieve these competencies. Once more fully implemented, an evaluation will be initiated to determine the degree to which these public health competencies are being achieved by family medicine graduates, especially whether they attained the knowledge, skills, and confidence necessary to effectively face diverse public health situations-from common to emergent.

Using a Web-based system to monitor practice profiles in primary care residency training.

OBJECTIVE: To explore the use of Web-based resident practice profiles (RPPs) as a means of tracking the clinical experiences of residents to ensure an adequate educational experience. DESIGN: Quantitative analysis of recorded patient encounters with residents. SETTING: The Department of Family and Community Medicine at St Michael's Hospital in Toronto, Ont. PARTICIPANTS: Twenty-seven residents enrolled in the department's training program between July 1, 2006, and June 30, 2007. MAIN OUTCOME MEASURES: The clinical experiences of residents with respect to patient demographic information, procedures performed, and diagnoses. Resident data were stratified by age, sex, training status, and source of medical degree, and RPPs were compared with patient profiles of physicians at the study site, at the university, and in provincial practices. RESULTS: A total of 9108 patient visits were recorded by the 27 residents during the academic year. Patient visit characteristics were very similar across all the resident variables except with respect to sex. The top 8 diagnoses encountered by residents were very similar to those of the comparison groups; anxiety or neurosis was the most common problem. Injections and Papanicolaou smears were the most common procedures, with 17.9 and 11.6 procedures, respectively, performed on average per resident during the study period. CONCLUSION: The RPP is an excellent Web-based tool to capture the clinical experience of postgraduate trainees. The practice profiles of the resident group were very similar to those of physicians in the study site, the university, and the province, demonstrating that common diagnoses made in practice correlate well with the clinical experience in residency.

Teaching pharmacotherapeutics to family medicine residents: a curriculum.

PROBLEM BEING ADDRESSED: Medication prescribing is becoming increasingly complex, and the need for formal curricula in pharmacotherapeutics and medication prescribing in accredited family medicine residency programs has been advocated. OBJECTIVE OF PROGRAM: The main objective of the pharmacotherapeutic curriculum is to support the development of family medicine residents' pharmacotherapeutic knowledge and medication prescribing skills required for rational prescribing. PROGRAM DESCRIPTION: The curriculum has 4 main components: 1) a medication prescribing framework based on the main tasks and key decisions related to the prescribing of medications, 2) 12 pharmacotherapeutic topics identified in the needs assessment, 3) a 5-step process for session design used by the curriculum development team, and 4) a description of specific roles of facilitators involved in delivering the curriculum. Formative evaluation of the curriculum using resident focus groups has helped to inform the further development of its components. CONCLUSION: A formalized curriculum was created to build knowledge of pharmacotherapeutics and effective medication prescribing skills, which are necessary for the current complex environment of patient care and medication management.