Family Medicine Residency Research Articles

Improving patient safety through mandatory quality improvement (QI) education in a family medicine residency programme

Although the American College of Graduate Medical Education (ACGME) requires that medical trainees acquire competencies in patient safety and quality improvement (QI), no standard curriculum exists. We envisaged that a...

Improving Family Medicine Residents' Provision of Gender-Affirming Care.

Family physicians are uniquely poised to provide gender-affirming care (GAC) to transgender and nonbinary patients, but current undergraduate and graduate medical education in this field is lacking. Little is known about the impact of various GAC curricula on the clinical care provided by resident physicians. We aimed to assess the efficacy of a multimodal educational framework on the quality of GAC provided by residents at a large academic family medicine program. This pilot study used chart review to assess the impact of a multifaceted educational intervention around GAC in an academic family medicine practice. Components included faculty-specific didactics, resident feedback and didactics, standardized note templates, and compiled resources. We completed pre- and postintervention analysis of resident-led GAC encounters using a novel rubric based on standards of care and compared these results using descriptive statistics. Following a multimodal educational intervention, residents demonstrated improvement in multiple domains of gender-affirming care, including documenting informed consent, counseling on pregnancy and contraception, and laboratory monitoring for patients initiating gender-affirming hormone therapy. This widespread improvement suggested that a multimodal approach to resident and faculty education may help enhance the quality of GAC provided by family medicine residents. Chart review offers a feasible and effective method for identifying gaps in resident knowledge and documentation in GAC. Further research should specifically explore faculty development in this area and expanded patient-centered quality metrics and outcomes that encompass GAC.

Family Medicine Residency Program Directors' Perception of Curricular Elements Related to Autism: A CERA Study.

The family medicine (FM) approach to health care across the life span is well-suited to providing care for persons living with autism spectrum disorder (ASD). Little is known about ASD curricula in FM residency training and the characteristics of FM residency programs that prepare their residents to care for persons with this disorder. Our study questions were part of a larger omnibus survey by the Council of Academic Family Medicine Educational Research Alliance (CERA) with data collection from November 16 to December 18, 2022, from FM residency program directors (PDs). ASD curricula were investigated using 10 questions, with descriptive analyses and nonparametric comparisons between program variables and ASD curriculum. The response rate was 42.18%, with FM PDs reporting that their programs were preparing residents in the care of youth (71.53%) and adults (68.33%) with ASD, but to a lesser extent (58.89%) in facilitating transitions of care. Programs with faculty champions, access to published curricula, sufficient patients with ASD, and engagement of interprofessional faculty reported a higher proportion of resident preparedness. PDs of community-based programs were most confident in their ability to teach ASD care and transitions of care. Most FM PDs modestly agreed that they are preparing residents to provide care to patients with ASD and their families. PDs of programs with greater access to resources (ie, published curriculum, faculty champions, sufficient patients with ASD, interprofessional faculty experts) believed that their residents were more prepared. Community-based FM educators may help lead the way in providing models for care and education in this regard.

Enhanced Scheduling to Improve Resident Continuity in a Family Medicine Teaching Clinic.

Continuity of care is a core concept at the heart of primary care practices. Increased patient-provider continuity of care is associated with better satisfaction scores, better clinical outcomes, decreased hospitalizations and emergency department utilization, improved completion of preventive health services, adherence to medical treatment plans, and improved show rates. Compared to traditional outpatient practices, resident teaching clinics traditionally have lower rates of continuity and face unique challenges in improving continuity given the curricular demands, complex scheduling, and high turnover of providers. The objective of our study was to assess the impact of front office training and new electronic medical record (EMR) scheduling protocols on resident continuity in a family medicine teaching clinic. From July 2021 through May 2022, optimized scheduling through a provider search function in the EMR was implemented in a family medicine teaching clinic. We compared the monthly continuity rates between corresponding months in the prior year and the intervention year. Over an 11-month implementation process, continuity for resident physicians increased from 36.4% to 64.6% (χ2=675.41, P<.001) using EMR tools and scheduling search functions to improve and sustain continuity over the study period. This intervention to enhance continuity in a family medicine residency clinic led to rapid and sustained improvement in provider continuity. This result demonstrates that optimization of EMR scheduling with tools and protocols can improve overall continuity. This scheduling process can likely be applied to clinical sites for residency programs across disciplines.

Burnout among family medicine residents: a cross-sectional nationwide study

BackgroundIn addition to pressures typical of other medical professions, family physicians face additional challenges such as building long-term relationships with patients, dealing with patients' social problems, and working at a high level of uncertainty. We aimed to assess the rate of burnout and factors associated with it among family medicine residents throughout Israel.MethodsA cross sectional study based on a self-administered questionnaire.ResultsNinety family medicine residents throughout Israel completed the questionnaire. The rate of clinically significant burnout, assessed by the composite Shirom-Melamed Burnout Questionnaire score, was 14.4%. In univariate analyses several personal and professional characteristics, as well as all tested psychological characteristics, showed significant associations with burnout. However, in the multivariable logistic regression only psychological work-related characteristics (work engagement, psychological flexibility (reverse scoring), and perceived work-related stress) were significantly associated with burnout at OR (95% CI) = 0.23 (0.06–0.60), 1.31 (1.10–1.71), and 1.16 (1.05–3.749), respectively.ConclusionThe integration of burnout prevention programs into academic courses during residency could explain the relatively low prevalence of burnout among family medicine residents in this study. Given the strong association of burnout with psychological characteristics, further investment in burnout prevention through targeted structured courses for residents should be encouraged.

Evaluation of Family Medicine Residency Programs for Diversity, Equity, and Inclusion Milestones.

In 2020, the Association of Family Medicine Residency Directors (AFMRD) Diversity and Health Equity (DHE) Task Force developed and piloted a framework to measure diversity, equity, and inclusion (DEI) initiatives in medical residencies across five domains: curriculum, evaluation, institution, resident pathway, and faculty pathway. The objectives were (1) to measure DEI initiatives across multiple domains in family medicine residencies using the DEI milestones and (2) to obtain current national baseline data providing criteria against which to measure effectiveness of initiatives and create tailored benchmarks. We developed a cross-sectional survey of 12 quantitative residency characteristic items and the five DEI milestone ratings, and distributed the survey to program directors of family medicine residencies accredited by the Accreditation Council for Graduate Medical Education in the spring of 2022. We generated descriptive statistics, including item frequencies and cross-tabulations, and completed subgroup comparisons with analysis of variance. We collected aggregate milestone data for 194 family medicine residencies of 588 eligible programs (33% response rate). Respondents represented 48 states and US territories: 107 community-based, university-affiliated; 48 community-based; 34 university-based; and 5 military/other programs. Overall, the curriculum milestone was rated the highest (mean=2.54, SD=1.03), whereas the faculty pathway (mean=1.94, SD=1.04) and resident pathway (mean=2.02, SD=1.06) milestones were rated lowest. DEI milestone data may support residency programs as they assess their institution's developmental progress across five key domains. Additionally, aggregate data may shed light on collective strengths and areas for improvement.

Resident Involvement in Curricular and Clinical Practice Change and Satisfaction With Training According to Length of Training in Family Medicine.

Most research in residency training has focused on quality improvement within a single program. We explored resident involvement in curricular and clinical practice change, the learning environment, and resident satisfaction in 3-year family medicine residencies compared to matched 4-year residencies. We used two surveys to capture data. One was for program directors, which assessed the level of resident involvement in curricular and practice transformation. The second was a resident survey, which asked residents to rate their involvement in curricular change and practice transformation, the learning environment, and satisfaction with training. Both were administered annually between 2013 and 2019. Response rates ranged from 84.6% to 100%. Findings revealed no overall difference in resident involvement in curricular change, but the program director survey findings indicated that a higher proportion of residents in 4-year programs were using a broader diversity of approaches to working on quality improvement (QI) projects compared to those in 3-year programs. We also found statistical differences in the number of QI projects completed per year, with 34.1% completing three or more in 4-year programs compared to 13.3% in 3-year programs (P<.001). We found a positive correlation between resident involvement, learning environment, and satisfaction with training for both 3-year (range 0.489-0.666; P=.001) and 4-year residents (range 0.441-0.529; P=.001). Four-year residents were involved in a greater number of quality improvement projects and had a more diverse profile of involvement than those in 3-year residency programs. Involvement in practice and curricular change and the learning environment were associated with greater levels of resident satisfaction with training in both 3-year and 4-year programs.

Assessing the impact of adopting a competency-based medical education framework and ACGME-I accreditation on educational outcomes in a family medicine residency program in Abu Dhabi Emirate, United Arab Emirates.

Competency-Based Medical Education (CBME) is now mandated by many graduate and undergraduate accreditation standards. Evaluating CBME is essential for quantifying its impact, finding supporting evidence for the efforts invested in accreditation processes, and determining future steps. The Ambulatory Healthcare Services (AHS) family medicine residency program has been accredited by the Accreditation Council of Graduate Medical Education-International (ACGME-I) since 2013. This study aims to report the Abu Dhabi program's experience in implementing CBME and accreditation. Compare the two residents' cohorts' performance pre-and post-ACGME-I accreditation.Study the bi-annually reported milestones as a graduating residents' performance prognostic tool. All residents in the program from 2008 to 2019 were included. They are called Cohort one-the intake from 2008 to 2012, before the ACGME accreditation, and Cohort two-the intake from 2013 to 2019, after the ACGME accreditation, with the milestones used. The mandatory annual in-training exam was used as an indication of the change in competency between the two cohorts. Among Cohort two ACGME-I, the biannual milestones data were studied to find the correlation between residents' early and graduating milestones. A total of 112 residents were included: 36 in Cohort one and 76 in Cohort two. In Cohort one, before the ACGME accreditation, no significant associations were identified between residents' graduation in-training exam and their early performance indicators, while in Cohort two, there were significant correlations between almost all performance metrics. Early milestones are correlated with the graduation in-training exam score. Linear regression confirmed this relationship after controlling the residents' undergraduate Grade Point Average (GPA). Competency development continues to improve even after residents complete training at Post Graduate Year, PGY4, as residents' achievement in PGY5 continues to improve. Improved achievement of residents after the introduction of the ACGME-I accreditation is evident. Additionally, the correlation between the graduation in-training exam and graduation milestones, with earlier milestones, suggests a possible use of early milestones in predicting outcomes.

Assessing Confidence of Family Medicine Residents in Performing Digital Rectal Examination in Jeddah, Saudi Arabia

Assessing Confidence of Family Medicine Residents in Performing Digital Rectal Examination in Jeddah, Saudi Arabia

Musculoskeletal Knowledge on the in-Training Examination Improves in Family Medicine Residents Participating in a Longitudinal Sports Medicine Clinical Track.

The study aims to assess the impacts of a sports medicine (SM) track on musculoskeletal (MSK) knowledge of family medicine (FM) residents. In-training examination (ITE) results were used to compare the MSK knowledge of FM residents with and without SM track participation. A single-center, retrospective study was completed on 85 FM residents from the 2018 to 2024 graduating classes who completed the ITE from 2017 to 2021. Residents were categorized by participation in the SM track, where half a day of FM continuity clinic per week is replaced with an SM clinic, supervised by a fellowship-trained SM physician. ITE scores throughout training were compared between the 2 groups using mixed-effects regression. The ITE MSK scores increased among both SM track participants (+77 points/year, p = .001) and nonparticipants (+39 points/year, p = .001) throughout their training. By postgraduate year 3, SM track participants performed significantly better on the MSK portion of the ITE (+87 points compared to non-participants, p = .045). No significant difference in total ITE scores was seen between groups. Our data demonstrates that participation in an SM track is associated with an increase in MSK knowledge of ITE, suggesting that an SM track may provide FM residents with a better understanding of MSK conditions.

Medical Error: Using Storytelling and Reflection to Impact Error Response Factors in Family Medicine Residents.

Medical error is common and significantly impacts patients, physicians, learners, and public perception of the medical system; however, residents receive little formal training on this topic. Research on error response in practicing physicians is limited, and even more so on medical education interventions to improve this. This study evaluates a curriculum developed to foster the sharing of faculty medical error stories, practice of constructive coping strategies, and growth in resident confidence in managing error. Researchers identified factors related to effective physician error management and recovery to develop a targeted intervention for family medicine residents. The intervention consisted of three one hour didactic sessions in a medium-sized midwestern, urban family medicine residency program over the course of 6 months. Instructional methods included guided reflection after mentor storytelling, small group discussion, role play, and self-reflection. Of the 30 residents, 22 (73%) completed the preintervention survey, and 15 (50%) completed the postintervention survey. While most residents reported having experienced error (55%), fewer than half of the residents reported they knew what to do when faced with medical errors (46%). This increased to 93% after intervention. Personal error stories from mentors were the most desired type of training reported by residents preintervention, but this was surpassed by legal and malpractice concerns in the postintervention survey. Rates of reported error story sharing increased after the intervention. Residents reported self-efficacy (I can be honest about errors) and self-awareness (I acknowledge when I am at increased risk for error) also increased with intervention. However, these changes did not reach statistical significance. Family medicine residents are receptive to learning from peers and mentors about error management and recovery. A brief intervention can impact the culture around disclosure and support. Future research should focus on the impact of targeted interventions on patient-oriented outcomes related to medical error.

Utilizing Community Procedure Clinics to Enhance Resident Procedural Education.

Procedure training in family medicine residency is important for future full-spectrum practice. Some residency programs have cited difficulty providing adequate procedure education. Residency collaboration with nonfaculty attending physicians working at community nonresidency clinics may help programs increase resident exposure to procedures. We assessed the feasibility of such an educational model by establishing recurring procedure clinics in a nonresidency family medicine site supervised by nonfaculty physicians. Twice monthly, half-day procedure clinics were conducted at a community site, where family medicine residents were supervised by nonfaculty community family physicians. After participation, we surveyed residents about their perceptions of the clinics. Using retrospective chart review, we determined quantity and type of procedures performed. Fifteen residents participated in 21 procedure clinics, featuring 18 procedure types and 268 procedures. Skin lesion excision, nail removal, punch and shave procedures, joint injection, newborn circumcision, and implantable contraception management were most consistently performed. Residents rated clinics highly and were satisfied with procedure number and variety, opportunity to learn new procedures and techniques, and feedback received. Over 80% of residents noted experiences in procedures that were less commonly encountered in their residency. Procedure clinics at a nonresidency site hosted by nonfaculty attending physicians provided additional training in a variety of primary care procedures. The clinics were favorable to residents and may help programs address training gaps.

"Not doing it justice": Perspectives of Recent Family Medicine Graduates on Mental Health and Addictions Training in Residency.

Family physicians report feeling inadequately prepared to meet the evolving mental health care needs of the population. Little scholarship exists evaluating the effectiveness of curricula designed to teach mental health and addiction (MH&A) care to family medicine (FM) residents. As such, the purpose of this study was to explore the experiences of recent FM residency graduates in providing mental health care, and their perceptions of mental health training gaps during their residencies. A qualitative descriptive study design was conducted by 8 recent graduates of the University of Toronto's FM residency program, who participated in semi-structured video interviews. A thematic analysis approach was used to collect and analyze the data. Through thematic analysis, 3 overarching themes were developed: (1) barriers in providing mental health and addiction care, (2) curriculum renewal, and (3) the role of FPs and professional identity. Consistent with the literature, the majority of recent FM graduates expressed discomfort when managing patients with mental health and addiction concerns. Additionally, participants perceived residency program time constraints, rotational site differences, and limited exposure to marginalized populations all impacted learning and mastery of skills. The findings of this study underscore current gaps within the FM residency curriculum and highlight the need to address current curricular deficits.

Family Medicine Resident Experience Toward Workplace-Based Assessment Form in Improving Clinical Teaching: An Exploratory Qualitative Study.

Workplace-Based Assessment (WPBA) has been widely utilized for assessing performance in training sites for both formative and summative purposes. Currently, with the recently updated duration of the family medicine (FM) training program in Saudi Arabia from four years to three years, the possible impact of such a change on assessment would need to be investigated.This objective was to explore the experiences of FM residents regarding the usage of WPBA as an assessment tool for improving clinical teaching at King Abdulaziz Hospital (KAH), Al Ahsa, Saudi Arabia. The study involves an exploratory qualitative phenomenological approach targeting family medicine resident in KAH was used. Purposive sampling techniques were used. In this descriptive study, data was collected through the utilization of 1:1 semi-structured interviews guided by directive prompts. All recorded interviews were transcribed verbatim. An inductive analytical approach was applied for thematic analysis of transcripts. Fifteen participants were individually interviewed until data saturation was reached. The themes that emerged were organized into the categories of underlying principles of WPBA, the impact of the learning environment, associated opportunities and challenges, and making WPBA more effective. Participants expressed that the orientation provided by the program was insufficient, although the core principles were clear to them. They valued the senior peers' support and encouragement for the creation of a positive learning environment. However, time limit, workload, and a lack of optimum ideal implementation reduced the educational value and effectiveness of WPBA among senior residents. The study examined residents' experiences with WPBA and concluded that low levels of satisfaction were attributed to implementation-related problems. Improvements should be made primarily in two areas: better use of available resources and more systematic prior planning. Revision and assignment of the selection process were suggested, in addition to the implementation of the new curriculum. The research will assist stakeholders in selecting and carrying out evaluation techniques that will enhance residents' abilities.

Assessment of knowledge and utilization of electrocardiogram by primary health care physicians and nurses in Qassim Region, Saudi Arabia

Objective: This study aimed to assess primary care physicians' and nurses' knowledge and utilization of electrocardiograms (ECG) in primary health care centers (PHCCs) in Qassim, Saudi Arabia. Methods: A cross-sectional study was conducted among PHCC physicians and nurses in Qassim Region, Saudia Arabia. An online self-administered questionnaire was used to obtain information about the knowledge and use of ECG. Results: A total of 320 physicians, family medicine residents, and nurses participated in the survey. Out of the participants, 174 (54.4%) were females. The majority (n=130, 40.6%) were aged between 31 and 40 years. In terms of the number of ECGs requested per week, approximately half of the participants, 158 (49.4%), requested ECGs two to five times per week. The most common reason for ECG requests was angina at 279 (87.2%), followed by arrhythmia at 139 (66.3%) and hypertension at 80 (25.0%). A majority of the doctors (56.3%) reported receiving ECG interpretation from senior colleagues. The most common ECG diagnosis reported was normal ECG among 296 (92.5%). Furthermore, 114 (35.6%) of the participants stated that they believed bedside teaching was the most effective way to improve ECG knowledge and its practical use. Conclusion: This study revealed that primary care physicians and nurses in Qassim, Saudi Arabia, had a limited understanding of and limited use for ECGs. It is strongly recommended to provide bedside training, hands-on tutorials during clinical rotations, and workshops/continuous medical education (CMEs) to enhance ECG knowledge, attitude, and utilization.

Knowledge and attitude about Autism among Family Medicine residents in Alahsa region, Saudi Arabia

Objective: This study aimed to assess the knowledge and attitude about autism among Family Medicine residents in the AlAhsa region, Saudi Arabia. Methods: A cross-sectional descriptive study was conducted from September to October 2023. A validated questionnaire was distributed among 99 Family Medicine residents through an online platform. The questionnaire assessed demographic data, knowledge about autism, and attitude toward managing the condition. Results: The results indicated a moderate level of knowledge about autism among the residents, where 51% displayed moderate knowledge, 24.5% showed good knowledge, and 24.5% had poor knowledge. Attitudes toward autism management were generally positive, though varied, highlighting a need for enhanced training and awareness. Conclusion: The study underscores the necessity for targeted educational interventions and continuous professional development to bridge knowledge gaps and improve the management of autism in primary care settings. Enhanced training on the diverse aspects of autism could lead to better patient outcomes and more effective healthcare delivery.

Evaluation of Interprofessional Delivery of Diabetes Medication Management Training Among Family Medicine Residents.

Diabetes-related care makes up approximately 24% of outpatient clinic visits. Therefore, confidence and understanding of diabetes management is necessary for family medicine residents. We developed a combined lecture and simulation lab curriculum utilizing a registered nurse and pharmacist to deliver education to 20 family medicine learners. Pre and post surveys of the educational material were completed in 2 sections including one gauging medical knowledge and a second part gauging level of comfort. Of the learners who participated, fourteen completed the pre-post surveys. Most (53%) respondents improved their scores, while 20% scored the same 27% scored worse. The overall average score increased 57% to 70% and improvement was statistically significant (P < .05). All learners improved confidence by at least 1 point. An interprofessional team utilizing a lecture curriculum focusing on providing education on effective prescribing, medication safety profiles, and resource availability, showed improvement in confidence but mixed knowledge benefit. Further modifications to the curriculum may yield further educational gains.

Pilot Study: Moving Towards a Scalable Intervention for Postgraduate Communication Skills Training.

Communication skills are foundational to the practice of medicine and training to build them is recommended. Serious illness communication skills (SICSs) teaching is inconsistently and sparsely taught in postgraduate training and residents report feeling inadequately trained to have difficult conversations. The authors developed an e-module demonstrating high-yield communication skills from a known evidence-based training program to standardize core SICS teaching and questioned how using it before skills practice impacted comfort and preparedness for residents to complete advance care planning (ACP). Family medicine residents at an academic hospital in Toronto, Canada, completed a novel e-module that replaced a typical didactic-lecture introducing core SICS relevant to ACP conversations. Residents then discussed the skills, followed by practicing them deliberately in a structured role-play simulation with feedback by trained facilitators. Residents completed pre- and post-intervention attitudinal surveys. Residents preferred a combination of learning modalities and welcomed online and virtual teaching methods for learning SICS. Residents reported higher levels of preparedness for engaging in ACP, delivering serious news, and discussing goals of care post-intervention. Residents showed more interest in discussing ACP post-intervention but questioned feasibility for doing so in busy ambulatory clinics. Scalable time-efficient teaching strategies are needed to fill a known education gap. This study demonstrated benefits of incorporating brief e-module learning into residents' preparation for SICS training using deliberate practice simulation training. The online, interactive virtual training improved resident readiness and comfort for ACP, an area often overlooked in medical education. Moreover, it provides an evidence-informed standardized tool for clinician teachers to seamlessly incorporate into their teaching practices.

The Role of Family Medicine in Addressing the Maternal Health Crisis in the United States.

The United States (US) is experiencing a maternal health crisis, with high rates of maternal morbidity and mortality. The US has the highest rates of pregnancy-related mortality among industrialized nations. Maternal mortality has more than quadrupled over the last decades. Rural areas and minoritized populations are disproportionately affected. Increased pregnancy-care workforce with greater participation from family medicine, greater collaborative care, and adequate postpartum care could prevent many maternal deaths. However, more than 40% of birthing people in the US receive no postpartum care. No singular solutions can address the complex contributors to the current situation, and efforts to address the crisis must address workforce shortages and improve care during and after pregnancy. This essay explores the role family medicine (FM) can play in addressing the crisis. We discuss pregnancy care training in FM residencies as well as the threats posed by financial and medico-legal climates to the maternal health workforce. We explore how collaborative care models and comprehensive postpartum care may impact the maternal health workforce. Efforts and resources devoted to high impact solutions for which FM has considerable autonomy, including collaborative and postpartum care, are likely to have greatest impact.

Constructivist On-line Learning Environment Survey (COLLES): avaliação do ensino híbrido em Programas de Residência

Abstract The research aimed to assess the effectiveness of blended learning in the Medical Residency Programs in Family and Community Medicine and Multiprofessional Residency in Family Health at the SESAU/Fiocruz. A cross-sectional observational study was conducted, utilizing a mixed-methods approach with the Constructivist Online Learning Environment Survey (COLLES) among enrolled residents in the first and second years. The study included 88 residents who showed a high level of agreement regarding the relevance of the programs to their professional practices, highlighting significant challenges in the process. Implementing blended learning emerged as an innovative and effective strategy in Residency Programs, evidencing a positive connection between theory and practice. Despite challenges in interactivity, the results suggest the need for strategies to enhance collaboration among residents, streamlining the learning experience. The use of blended learning is a promising tool in Residency Programs, contributing significantly to professional development.