Assessing undergraduate medical education through a generalist lens.

PROBLEM BEING ADDRESSED: Medical schools aim to integrate the values of generalism into their undergraduate programs. However, currently no program has been described to measure the degree to which formal curricular materials represent generalist principles. OBJECTIVE OF PROGRAM: To quantify the generalism principles present in undergraduate medical education learning materials and to provide recommendations to enhance generalism content. PROGRAM DESCRIPTION: A review of the literature and accreditation documents was conducted to identify key elements of medical generalism. An evidence-informed tool, the Toronto Generalism Assessment Tool, was developed and applied to the new preclerkship undergraduate cases at the University of Toronto in Ontario. The findings regarding the presence of generalism principles and recommendations to enhance generalism content were provided to case developers. The recommendations were valued and were incorporated into subsequent iterations of the cases. CONCLUSION: This is the first report of a successful evidence-informed program to assess the degree of generalism reflected in undergraduate medical education curricular documents. This program can be used by other institutions wishing to review their curricula through a generalist lens.

Family medicine residents' perspectives on curricular messaging surrounding enhanced skills fellowship programs.

OBJECTIVE: To better understand the messages that family medicine residents receive about enhanced skills fellowship programs throughout their training. DESIGN: Phenomenologic approach using structured qualitative interviews. SETTING: Postgraduate family medicine program in Ontario. PARTICIPANTS: Eleven family medicine residents (5 first-year and 6 second-year residents) from 4 separate training sites. METHODS: Interviews were audiotaped and codes were developed by the study investigators. Themes arose from the data via the immersion and crystallization technique. MAIN FINDINGS: Themes emerged in 3 categories: perception of purpose, sources of messaging, and formal or informal versus hidden curricular messages. Fellowship programs were viewed by residents in terms of their personal and professional benefits. Residents learned about fellowship programs through word of mouth and from role models. The formal curriculum remained neutral about fellowship training. The hidden curriculum highlighted a number of messages: a) to maximize chances of acceptance into some fellowship programs, one should focus most of his or her elective time in that clinical area; b) many fellowships graduate subspecialists to the exclusion of family medicine; c) a fellowship is required to practise in a large urban centre but is not required to practise in rural communities; and d) those without fellowship training are less well regarded. CONCLUSION: Residents receive mixed messages regarding fellowship training. This might be a phenomenon isolated to a larger urban centre in Ontario. Decision making at the individual level in terms of career path seems to be affected and might have implications at the larger system level.

Introduction of a Motivational Interviewing Curriculum for Family Medicine Residents.

BACKGROUND AND OBJECTIVES: The literature has shown that Motivational Interviewing (MI) education can be successfully implemented within the residency education environment; however, little research has described how to implement such a curriculum. We propose that residents' MI skills and confidence will increase following participation in an MI curriculum. METHODS: Thirty family medicine residents were invited to participate in an 8-hour MI curriculum. Residents completed pre- and post-course confidence questionnaires and the Helpful Responses Questionnaire (HRQ). Wilcoxin Rank Test was used to assess rank differences between pre- and post-course self-confidence ratings, and paired t tests were used to assess effect sizes of the curriculum on HRQ responses. Study outcomes included residents' self-perceived confidence in using MI skills and MI skill performance measured by HRQ scores. RESULTS: Residents demonstrated an increase in confidence ratings after the course (n=21, mean before course: 4.19, 2.1 SD; mean after course: 6.71, SD 1.1). Both reviewers found an improvement in HRQ scores after course completion (Reviewer 1: Mean difference=6.05, 95% CI=2.83--8.26, Reviewer 2: Mean difference 4.19, 95% CI=2.19--6.19). CONCLUSIONS: There was a statistically significant increase in residents' self-confidence ratings, as well as an improvement in MI skills post-intervention, as evidenced by a statistically significant improvement in MI-consistent HRQ scores.

Family practice registered nurses: The time has come.

OBJECTIVE: To provide a picture of the unique role and competencies of family practice registered nurses (FP-RNs). DESIGN: Case-study approach using interviews and focus groups. SETTING: Ontario. PARTICIPANTS: Seven FP-RNs identified as exemplary by family medicine and nursing peers. METHODS: An e-mail was sent to 9200 health care providers from nursing and family medicine, asking them to identify names of exemplary family practice nurses. Using a purposive sampling methodology, 7 exemplary FP-RNs were selected, taking into consideration the number of years in practice as a nurse, location of practice, length of practice as an FP-RN, and type of family practice. Individual interviews were held, and focus groups were organized with colleagues. Narratives were analyzed iteratively by the project team. MAIN FINDINGS: Four main themes emerged: The first theme relates to the relationship-centred approach to care delivered by FP-RNs, founded upon trust. The second theme highlights the FP-RN's unique skills in balancing the priorities of patients, colleagues, and the clinic as a whole. The third theme capitalizes on the nurses' commitment to advancing their learning to enhance their abilities to be FP-RNs. The fourth theme illuminates the perspectives shared by FP-RNs that family practice is uniquely different from acute care in the manner in which care is delivered. We draw attention to the approach and role of FP-RNs in Ontario. The 4 themes that emerged have striking similarities to stories shared by family physicians and to the evolutionary development of the discipline of family medicine. CONCLUSION: We believe the findings from this paper can help shape the role of the FP-RN within clinical practice and that they will propagate discussion among nursing educators to consider the necessary educational preparation required to develop the FP-RNs needed in this country.

A Delphi approach to developing a core competency framework for family practice registered nurses in Ontario.

This paper describes the results of a Delphi panel process to gain consensus on a role description and competency framework for family practice registered nurses (FP-RNs) in Ontario. Based on the findings from interviews and focus groups with family practice registered nurses and their inter-professional colleagues throughout Ontario, a core competency framework for FP-RNs emerged consisting of six distinct roles - Professional, Expert, Communicator, Synergist, Health Educator and Lifelong Learner - with accompanying enabling competency statements. This framework was refined and validated by a panel of experts from various nursing and family medicine associations and organizations through a Delphi consensus process. This core competency framework for FP-RNs was developed as a stepping stone for clarifying this very important and poorly understood role in family practice. As a result of this research, we expect a greater acknowledgement of the contributions and expertise of the FP-RN as well as the need to celebrate and profile this role. This work has already led to the establishment of a network of stakeholders from nursing organizations in Ontario who are considering opportunities to move the development and use of the competency framework forward.