HIGHLIGHTS OF THE INNOVATION SHOWCASE.

Should a Pharmacy Dean be a Pharmacist?

Geisinger Commonwealth School of Medicine.

Canadian family medicine (FM) residency programs are required to provide teaching opportunities to trainees to enable the development of teaching skills in order for residents to become the next generation of FM teachers. The College of Family Physicians of Canada's Fundamental Teaching Activities (FTA) Framework outlines the roles, tasks, and activities expected of FM teachers across three domains: Clinical Preceptor, Teacher Outside the Clinical Setting, and Educational Leader. The purpose of this study was to describe resident teaching opportunities within a Canadian FM residency program and examine the degree to which they align with the domains of the FTA Framework. This was a qualitative study employing one-on-one semistructured virtual interviews with 10 rural and urban FM residents and 12 academic teachers from May 2021 to May 2022. Interviews explored FM resident teaching opportunities, including the setting where the teaching occurred, who the learners were, and the teaching topics. Qualitative, iterative thematic data analysis techniques were used with a coding template. Mapping resident teaching opportunities onto the FTA Framework required some modifications. The Clinical Preceptor domain was refined to Clinical Teacher; the Teacher Outside the Clinical Setting domain remained unchanged; and a new domain of Educational Collaborator emerged. Resident teaching opportunities spanned diverse settings, including outpatient clinics, inpatient hospital wards, large/small groups, and one-on-one sessions. These activities included direct clinical teaching, curriculum development, and peer education. The study findings suggest that a FM resident-specific teaching framework is warranted to help guide residents and academic teachers to optimize FM resident teaching opportunities.

Preventing Today's GME Disasters: Lessons Learned From a Failed Contract Renewal.

Family Medicine (FM) is the care of unselected patients with undifferentiated problems in the settings where people need care in our communities. It is intellectually challenging, providing breadth and depth unparalleled in other areas of medical practice. In one survey only 19% of Israeli students reported being interested in FM. Students interested in FM had greater interest in bedside and direct long-term patient care. Students not planning FM residency training had preconceived notions that the discipline had lower academic opportunities and prestige. What can be done to increase student interest in careers in FM?This commentary includes perspectives of family practice leaders from several countries:The problem isn’t the students it is the scope of practice and expectations both of which can and should change if FM in Israel wants to stay viable. The scope of FM should be broadened to include more procedures and new technologies. This may also increase the earning potential of Family Practitioners (FPs). Payment policy and credentialing barriers should be change to expand scope of practice and allow FPs to practice at the full extent of their training.FM should offer clear professional horizon with potential for many sub-specialties and areas of focus. The Israeli HMOs, the Ministry of Health and the Israeli Association of FM should invest heavily in building academic departments of FM and promoting research. This will enhance the image of FM in the eyes of the students, the profession and the public.The clinical work environment should be improved by reducing bureaucratic assignments, such as issuing certifications, dealing with quality measurements and renewing chronic prescriptions. Much of this work can be done by nurse practitioners (NPs) working as part of an FP-led team. These NPs can also take care of patients with limited complaints to make the work of the FP more challenging and attractive.Training must include opportunities to develop longitudinal relationships with patients and families across problems and over time. It is these relationships that add value to the process of care, improve patient outcomes and provide meaning to sustain clinical careers that meet the needs of patients and communities.

BackgroundClinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6 months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs.Methods/designWe propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment.The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6 months post-intervention, using 95 % confidence intervals. A linear multilevel regression will be used to adjust the model.DiscussionThe identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance.Trial registrationClinicalTrials.gov: NCT02210442.

The high quality of obstetric care provided by certified nurse midwives (CNMs) has led some to hypothesize that collaboration with CNMs may encourage more family medicine (FM) residents to subsequently practice maternity care. Our goal was to understand the current state of CNM involvement in FM resident education. We conducted two surveys: one to a random sample of 180 FM program directors, and one to 147 CNMs involved in medical education. The surveys examined the nature, prevalence, and attitudes regarding CNM involvement in FM residency training. The surveys' response rate was 59% from FM program directors and 58% from CNMs. Thirty-six percent of FM directors reported no CNM involvement in their residency programs, 26% reported minimal interaction, and only 6% reported a fully integrated model with CNMs on faculty. Eighty-eight percent of CNMs and 64% of program directors reported a prefence for increased interaction. Programs with highly involved CNMs reported 33% of graduates subsequently practicing prenatal care, with only 13% of graduates practicing in programs with low CNM involvement (P<.003). However, there was no difference in those providing inpatient maternity care. Thirty-one percent of FM program directors and 25% of CNMs felt that physicians and CNMs have different ideas about how to treat patients; 26% of FM program directors who worked with midwives felt that CNMs should not be involved in residency curriculum planning. CNM participation in FM residency education is very limited. Our study identified a gap between the current state and the preferences of CNMs and FM program directors for greater educational collaboration. Residency program director attitudes may contribute to the low rate of collaboration between the two fields.

Why is it that in spite of many reports that identify the limitations of current health care systems and recommend transformative solutions, change has been painfully slow and disappointingly limited? One critical factor is the influence of leaders who understand that health care is a complex adaptive system.1–3 Because of their training and experience as generalists who deal with undifferentiated illness, family physicians are particularly suited to leadership in current health care environments where evidence is often incomplete and the way forward is uncertain. These limitations are especially evident in primary care. We are challenged both to include education for values-driven leadership as a core competency and to inspire family physicians to seek out and embrace leadership opportunities. In a 2011 response paper1 to an article by Lindstrom et al2 on collaborative health policy making, Allan Best and I suggested a 6-factor framework for implementation of change in health systems, including values, governance, learning networks, innovation research, systems thinking, and leadership (Figure 1). A key principle in this framework is leadership—and not just any kind of leadership. We argue that leaders are needed who can develop working partnerships, grounded in shared values and understanding of the need for systems thinking in health care. Core values are patient and family-centered care, social responsibility, and equity; commitment to change in outcomes; and an evidence-informed approach that integrates research, theory, and practice knowledge in action. If change is to be achieved, these core values must be shared by leaders across the health professions, administration in our institutions, and relevant government departments. Figure 1 Implementation framework for change in health care. Leaders who understand complex systems know they can and must rely on facilitation and empowerment and participatory action methods, rather than on “command and control”; that they must continuously evaluate outcomes and make further changes iteratively: “Instead of attempting to impose a course of action, leaders must patiently allow the path forward to reveal itself.”4 Leaders must model openness, risk taking, and reflection, and communicate a compelling vision of what will be achieved by implementation of change. They need to provide support and advocacy to lead others to embrace the vision while appreciating diversity of opinions.5–7 They must recognize that their colleagues may be risk averse or overloaded with other demands, and that change may come slower than desired. Patience and excellent team and communication skills are essential. At the same time, the environments where leaders work need to encourage risk taking and to see unsuccessful interventions as opportunities for learning and modification, rather than personal failures. This is not the case at present. Can our health care institutions become safe and encouraging places for health care leaders and innovation, and improve the likelihood that attempted changes are both effective and sustainable? How can leaders from medicine, nursing, and other health professions advocate effectively for our health care environments, including community-based settings, to become learning organizations and networks? Meanwhile we can develop and nurture medical leaders within primary care. We can incorporate formal leadership education for medical students and family medicine residents8,9 that goes beyond traditional leadership skills training, to ensure that our graduates understand how complex systems function and how to lead within self-organizing structures. We can provide opportunities for participation in real-life change situations within hospitals, outpatient practices, health care/community partner collaborations, and other situations so learners can experience how shared leadership models work. Medical learners can appreciate that sometimes change strategies will be best led or co-led by leaders from other health professions, particularly nursing, or by managers. We can drive home the message that, by being values-driven leaders, physicians can influence contemplated solutions to health care problems so that changes result, not only in cost savings, but also in improvements in patient and family-centered care and equity. If we really want our future family physicians to become leaders, we must model leadership ourselves. Instead of complaining about the system, we can take up leadership opportunities and advocate for patients and families, for equitable care, and for healthy communities.10 By demonstrating values-driven principled leadership, we can inspire our colleagues to invest their time and energy into leading change. If enough leaders emerge who have a sophisticated appreciation of how the system operates, optimism that change is possible, and an unshakeable belief that evidence-informed change with measurement of outcomes is the only sensible way to deal with health care problems that confront us, maybe we can actually move from talk to action.

Are university-based residency training programs lacking in resident education of proper diagnosis and treatment for common skin and breast lesions?

The last few decades have seen great changes in health care and medical care in Greece, as well as in the Greek university system. A new law on health care and medical care has come into force, a new university hospital and new health centres have been built, and a faculty of medicine has been established at Heraklion in Crete. People are speaking of a change of paradigm. Simultaneous with the introduction of the new national health care system, the Department of Family and Social Medicine (DFSM) in Crete started a major project on public health, known as the Primary Health Care and Nutrition Programs (abbreviated as PPD). The purpose was to chart the state of health and living conditions of the Cretan population in the period 1986-1990. Cooperation in research and training began between DFSM and the Dalby Health Sciences Centre, Lund University in 1987. This was natural since there was a shared interest in research into family medicine and social medicine. In addition, a new Health Care Act had come into force in Sweden in 1982. The establishment phase of primary health care started in Sweden at the end of the 1960s. In the 1970s health centres were established, along with research and training in family medicine, in a way that is comparable in many respects to the situation in which Crete found itself a decade later. This paper concerns the organization and implementation of PPD and the research cooperation between Greek and Swedish institutions. This can be seen as an expression of the internationalization of research for which the two universities have striven.

BackgroundTo describe the supply, distribution, and characteristics of international medical graduates (IMGs) in family medicine who provide patient care in the U.S.MethodsA cross-sectional study design, using descriptive statistics on combined data from the Educational Commission for Foreign Medical Graduates and the American Medical Association, including medical school attended, country of medical school, and citizenship when entering medical school.ResultsIn total, 118,817 physicians in family medicine were identified, with IMGs representing 23.8% (n = 28,227) of the U.S. patient care workforce. Of all 9579 residents in family medicine, 36.0% (n = 3452) are IMGS. In total, 35.9% of IMGs attended medical school in the Caribbean (n = 10,136); 19.9% in South-Central Asia (n = 5607) and 9.1% in South-Eastern Asia (n = 2565). The most common countries of medical school training were Dominica, Mexico, and Sint Maarten. Of all IMGs in family medicine who attended medical school in the Caribbean, 74.5% were U.S. citizens. In total, 40.5% of all IMGs in family medicine held U.S. citizenship at entry to medical school. IMGs comprise almost 40% of the family medicine workforce in Florida, New Jersey and New York.ConclusionsIMGs play an important role in the U.S. family medicine workforce. Many IMGs are U.S. citizens who studied abroad and then returned to the U.S. for graduate training. Given the shortage of family physicians, and the large number of IMGs in graduate training programs, IMGs will continue to play a role in the U.S. physician workforce for some time to come. Many factors, including the supply of residency training positions, could eventually restrict the number of IMGs entering the U.S., including those contributing to family practice.

Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson's correlation tested associations between module usage, scores, and ITE scores. A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.

Family medicine has not received appropriate attention in the sub-Saharan African context. In particular, family medicine is rarely recognised as a medical speciality and most African countries are silent on the role of family medicine in their health systems. There is, however, an emerging interest in developing family medicine as a key component of primary healthcare. Postgraduate training in family medicine is progressing and many countries have already established specific training programmes. In addition, there have been attempts to define the importance of family medicine, which, we expect, this short report contributes to. Interviews were conducted with physicians, partners and beneficiaries of two international development projects funded by the Canadian government. The one project supports training of health professionals and the other education of healthy women and girls in the community. The objective was to document the strengthening of primary healthcare through the creation and adaptation of a new family and community medicine postgraduate medical programme (which includes both family and community medicine) emphasising field training, immersion in local communities and interdisciplinary collaboration. This article underlines the importance of family medicine in Mali by documenting how what is now termed family and community medicine can promote community-orientated health services. To do so, we use the examples of initiatives and actions done through two international health development projects.

Cancer survivors need high-quality follow-up care that addresses long-term problems related to cancer and their treatment. With growing numbers of cancer patients transitioning from oncological treatment to survivorship care, primary care physicians (PCPs) will play a major role in the delivery of survivorship care. This pilot study was undertaken to provide initial insights into internal medicine (IM) and family medicine (FM) residents' educational experience, training, and preparedness for practice as healthcare providers of adult cancer survivors (ACS). This study utilizes an anonymous cross-sectional, electronic survey of a sample of US IM and FM residents. A total of 77 residents in their PGY-3 year of training responded to the survey, including 53 IM (69%) and 24 FM (31%) residents. The majority (97%) of respondents performed as PCPs for ACS during their training, and 81% expected to take care of such patients in the future. However, only a minority reported feeling very comfortable in this role or very confident of identifying cancer recurrence and potential long-term effects of cancer treatment (13%, 21%, and 15%, respectively). Formal education in survivorship care was reported by 27% of residents and was modestly associated with knowledge responses. High clinical exposure (defined as having ≥10 opportunities to perform as the PCP for ACS) was significantly associated with self-reported knowledge, comfort level, and self-confidence in being able to evaluate and manage potential long-term effects of cancer treatment and their symptoms. Our results suggest there is a substantial disconnect between resident's educational experience, training, and self-reported preparedness for practice in cancer survivorship in both IM and FM training specialties. Inadequate training in cancer survivorship represents a barrier to providing adequate cancer follow-up. Inexperience or unawareness of essential survivorship issues could lead to mistakes which affect survivors' health and timely assessment of long-term cancer-associated morbidity. As PCPs will play a key role in the delivery of survivorship care, effective educational opportunities and achievement of competencies in adult cancer survivorship care by primary care trainees are needed.

Introduction: Career choices by newly graduated doctors play an important role in the provision of health care and for the making of health policies. Family Medicine is not being recognized as a specialty of choice among the health care society. The objective of this study was to see the preference of final year medical students towards family medicine as a career choice and its associated factors. Methodology: This was a cross sectional study conducted among final year medical students of private and government medical colleges who were exposed and not exposed to family medicine teaching, after taking informed consent. Results: Out of a total of 175 students 158 planned to go for specialization. Among them a small number, 16 from government and 4 from a private university, planned to join family medicine residency. The majority (74) from private university believed that there is a difference between general practitioner and family physician. Nearly all of them (75) believed holistic care approach as a main domain of family physicians. All private and few government university students said that Family Medicine should be incorporated as a subject in the undergraduate medical curriculum. Recommendations: Family Medicine is in its infancy stage and requires the dire need to increase its awareness through sessions and seminars among health care professionals. Key words: Family medicine, career choice, medical students