Section of Teachers of Family Medicine Volume 14, Number 1, Spring 2006

1. From the Editor's Desk
2. Family Medicine And Diversity Education: An Integrated Approach
3. The WGCP: Presentation On The Working Group On The Certification Process
4. The Canmeds Physician Competency Framework
5. The Four Principles
6. Exciting Initiatives In Undergraduate Education
7. Globally Speaking: A North American Initiative To Increase Japanese Student Interest In Family Medicine  
8. House Calls – An NFB Documentary Film
9. To Go Where No Clinical Clerk Has Gone Before - A Surprising Way To Initiate Medical Students To House Calls
10. Faculty Development Day at FMF December 8th, 2005
11. A Faculty Development Program for Teachers of International Medical Graduates
12. Section Of Teachers Executive
    

From the Editor's Desk

by Maureen Rappaport, MD, CCFP, FCFP

This newsletter highlights the plenary sessions that took place at the Family Medicine Education Forum in Vancouver in December 2005. The title, Core Ideas to Core Competencies: Creating the Future of Family Medicine, was, indeed, an ambitious one for our day. The objectives of the education forum were: 1) to understand how the Four Principles of Family Medicine and the CanMEDS roles can be integrated in family medicine education; and, 2) to provide guidance to the College’s “Working Group on Certification” and “Project on Family medicine in Undergraduate Medical Education” in defining core competency in family medicine.

In this issue Drs. Blye Frank, Tim Allen, Jason Frank, and Paul Rainsberry summarize the sessions they delivered at the Education Forum. Blye Frank cautions us to be certain of our first principles as he links values, social accountability, CanMEDS, and the Four Principles to Diversity Education. Tim Allen succinctly explains the complicated process the Working Group on Certification went through to ensure its thoroughness and integrity. Jason Frank writes about the historical development of CanMEDS and the crucial roles members of our college and our Four Principles played in their development. Lastly, Paul Rainsberry takes us back to the initial development of the Four Principles in the 1980s which became both a way to define Family Medicine and the foundation on which our educational process would proceed.

This newsletter also contains articles that speak to the very principles we are struggling to defend. Meredith McKague tells us about the important initiatives in Undergraduate Education, at a time when our undergraduate programs are expanding and playing a crucial role in the future recruitment of residents. Eric Cadesky exemplifies the leadership our residents are capable of with his initiative in Japan. Mark Nowaczynski shows us how he blends his artistic and medical passions in the development of the social action film, House Calls. And Steve DiTommaso shows and tells us his unique way to teach home care, a community practice that is truly unique to family doctors.

As you read through this newsletter, I’d like you to keep the following questions in mind. These were the questions we struggled with in small group discussions the day of the Education Forum.

1) Define the relationship between the roles, principles, and core competencies.
2) How would we preserve the priority of the Four Principles in a CanMEDS medical education world?
3) What are the competencies that define Family Medicine as a distinct discipline?
4) Are the CanMEDS roles sufficient in themselves to define a Family Medicine curriculum?

Our recommendations at the end of the day were that we were very attached to our principles. We wanted to keep our principles printed in the foreground of a cube listing the CanMEDS roles on the surface. We also wanted to keep the patient in the centre of all of what we do.

FAMILY MEDICINE EDUCATION FORUM (FMEF) 2005

FAMILY MEDICINE AND DIVERSITY EDUCATION: AN INTEGRATED APPROACH

by Blye Frank, PhD, Professor, Division of Medical Education, Dalhousie University, Halifax, Nova Scotia, Canada. Anna MacLeod, PhD candidate, University of South Australia, Adelaide, South Australia, Australia

Of all the forms of inequality, injustice in health is the most shocking and inhumane.

Martin Luther King Jr.

As health care providers, family physicians are operating within a frame of social accountability. Our understanding of ‘social accountability’ in the Canadian context is informed by four key sources:

1) Building on values: the future of health care in Canada (Romanow Report)
2) Social accountability: a vision for Canadian medical schools
3) Skills for the new millenium: report of the societal needs working group, CanMEDS 2000 project
4) The four principles of family medicine

Social accountability has been defined as

The obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public. (WHO 1995) (2)

In Canada, and around the world, the communities we serve are becoming increasingly diverse. There is an abundance of research indicating that members of historically marginalized groups have received, and in many instances continue to receive, health care that is inequitable (5). Although increased attention is being directed at these critical issues; health disparities persist (5).

Initiatives such as “Social Accountability: A Vision for Canadian Medical Schools” (2) recognize that as educators and as family physicians, we have the ability to contribute to the reduction of health disparities by educating physicians who will offer accessible and equitable care. Many well-intended diversity education initiatives and interventions have been developed in response. We applaud medical educators for recognizing and responding to these issues; however, it is our position that diversity education must be approached from a critical perspective. This involves being reflective about such issues as: Who are our patients? The family? The community? Indeed, who is the physician?

When diversity education is delivered incidentally (“half day workshop on cultural diversity” for example), despite good intentions, this may actually contribute to the continuation of “stereotypes about what members of a particular culture believe, do, or want and how they should be dealt with” (6). Thus, careless diversity education has the potential to reproduce the very health disparities which it was intended to reduce. We refer to non-critical diversity education “The Four ‘Ds’ of Multiculturalism” approach (7) – meaning we invite members of diverse groups to educate us about them. The scope of this education rarely reaches beyond a “Tell us about the Dress, Diet, Dialect and Dance of your culture”– hence the 4 ‘Ds’.

Let us be clear - we are not opposed to the celebration of diversity or multiculturalism. However, such an educational approach really does not offer much to family physicians who are working with a diversity of individuals. Instead, stereotypes may be perpetuated and critical issues such as discrimination, health disparities, and structural inequities are often overlooked.

We favour an approach that weaves diversity issues into the fabric of the institutional climate, encouraging learners to be reflective about inequities and discrimination within medical education, the patient-physician relationship and health care delivery more broadly - “taking difference into account.” Diversity issues are thus considered across language; pedagogy; curriculum; and, policy of a given institution. As socially accountable family physicians, this involves thinking about how issues of diversity permeate our four guiding principles (4).

1. The family physician is a skilled clinician – This involves thinking about what patient-centered care means in the context of a diverse society.
2. Family medicine is a community based discipline – This entails the ability of family physicians to respond to the evolving needs of diverse communities.
3. The family physician is a resource to a defined practice population – This means organizing our practices to take into account the health concerns of a diverse patient base.
4. The patient-physician relationship is central to the role of the family physician – This suggests the need to develop intercultural awareness, meaning becoming aware not only of ‘others’ but also of ourselves.

Taking differences into account throughout our institutional practices helps to ensure that diversity is integral and considered more than a curricular “add on.” It is through this type of educational approach that thoughtful consideration of difference becomes fundamental to the education and professional development of family physicians.

At Dalhousie University, we have responded to these issues through the development of the Changing Worlds: Diversity and Health Care program, which is funded by the Department of Canadian Heritage. Based on the expertise and guidance of an interdisciplinary advisory committee, a planning group and an evaluation committee, this program delivers weekly seminars, journal clubs, information sessions and film viewings for faculty, staff and students in the Faculties of Medicine, Dentistry, and Health Professions at Dalhousie University. These sessions focus on health disparities, inequities and discrimination, working and teaching in diverse settings and health care delivery. The events have been well-attended and evaluations have been positive and informative. Through this educational program, it is our goal to make a contribution to both institutional change with regard to diversity education and the reduction of health disparities for members of historically marginalized group. We subscribe to the philosophy of Mahatma Gandhi that ‘We must be the change we want to see in the world.’

References

1. Romanow RJ. Building on values: the future of health care in Canada — final report. Saskatoon, Saskatchewan: Commission on the Future of Health Care in Canada, 2002. Available at: www.hc-sc.gc.ca/english/care/romanow/hcc0086.html (accessed 2004 Mar 30).

2. Social accountability: a vision for Canadian medical schools. Ottawa: Health Canada; 2001. Cat no H39-602/2002. Available: www.hc-sc.gc.ca/hppb/healthcare/pdf/socialaccountability.pdf (accessed 2004 Mar 30).

3. Frank JR, Jabbour M, Tugwell P et al. Skills for the new millenium : report of the societal needs working group, CanMEDS 2000 project. Annals Royal College of Physicians and Surgeons of Canada 1996; 29:206-216.

4. College of Family Physicians of Canada. The four principles of family medicine. Toronto: The College; 1999.

5. Institute of Medicine (US). Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington: The National Academies Press; 2003.

6. Taylor J. Confronting ‘culture in medicine’s ‘culture of no culture.’ Acad Med 2003; 78:55-9.

7. Frank B., MacLeod A. Beyond the “four Ds of multiculturalism”: Taking difference into account in medical education. Med Ed 2005, 39: 1178-1179.

THE WGCP: PRESENTATION ON THE WORKING GROUP ON THE CERTIFICATION PROCESS
by Tim Allen, MD, Université Laval

The mandate of the WGCP (Working Group on Certification Process) is to develop a competency based definition of Family Medicine and to direct changes to the certification process while reporting to the Board of Governors. Our challenge was to link the theory of competence in a family doctor with the practice of a certification process. This high stakes certification must be valid, reliable, accepted by users, have a positive educational impact, and be cost effective.

We first had to define, in much detail, competence in Family Medicine. This definition was derived by surveys, focus groups, and validation studies. A list of 99 Priority Topics was generated by asking practicing family physicians what topics (problems, diagnoses, and situations) a competent family physician should be able to deal with at the start of independent practice. The data was collected by semi-structured survey questionnaires and compiled before review by focus groups. The priority topics (like depression, hypertension, pregnancy, periodic health) were too broad to usefully direct the design of applications. To reach the five goals of certification outlined in the first paragraph we need to identify the critical elements and higher levels of competence in dealing with these topics in the specific context of family medicine. The method used to identify and define these interactions was a Key Feature analysis.

Key features represent the critical, or essential steps in the resolution of a clinical situation or problem. If you think carefully about it, for any particular problem we tend to make mistakes or miss things or perform poorly only at certain points in the clinical encounter, and that these points are quite specific to the problem at hand. As a rule, key features are observable actions; they are processes or skills and not simple knowledge. Key features are generated based on clinical experience, not on theoretical considerations. The number of key features will vary greatly from one problem to another. The key features are generated by a group of practicing physicians, basing their analysis on the real-life solution of problems in Family Medicine. They identify the higher levels of competence and the skills that distinguish between competent and non-competent candidates, and they identify criteria that can be used to objectively assess performances in test situations. The key feature are not in themselves test items, but they are signposts that clearly suggest both content and format of the test items that are most appropriate for testing. We have a list of 99 Priority Topics and Key Features for 75 of these topics. There is an average of 7.5 key features per topic so all 99 topics we will describe about 750 competencies in Family Medicine. We also have a list of 65 core procedures that were identified as essential for the competent practice of family medicine.

Overall competence, however, encompasses several interacting dimensions ; 1) a set of problems (priority topics and core procedures), 2) a set of skills (patient centered method, clinical reasoning skills, selectivity, communication skills, and professionalism), 3) a context (physician patient relationship and all phases of the clinical encounter), and 4) levels of competence (higher levels which are more predictive of life-long competence and some lower level experiential competence). Work is ongoing, developing the definition in terms of these dimensions, using a key feature analysis to make sure we get interactions right and to maximize our chances of meeting the five objectives for high-stakes evaluations.

In conclusion, the complete operational definition of competence in Family Medicine will help us to better design future modifications to the certification process. It will also help us to have a clearer idea of what is being assessed (and what isn’t). The assessment of our candidates will concentrate as much on the skills and processes used to deal with problems as it does on the actual answers or solutions to specific problems. We believe that it will be safe to say that a candidate who can demonstrate competence in dealing with the topics/key features and procedures on our list, and can do this in the context of Family Medicine, demonstrating higher levels of competence, using the appropriate cognitive skills, in all phases of the physician-patient encounter, and with respect to the Four Principles of Family Medicine, does indeed deserve certification to start independent practice.

THE CANMEDS PHYSICIAN COMPETENCY FRAMEWORK
by Jason Frank, MD MA(Ed) FRCPC, Associate Director, Office of Education, Royal College of Physicians and Surgeons of Canada

In the early 1990’s, a forward-thinking group of medical educators, the College of Family Physicians of Canada and Fellows of the Royal College of Physicians and Surgeons of Canada, and other healthcare professionals developed an innovative framework for medical education called the CanMEDS framework of essential physician competencies.

This Canadian framework is organized around seven “CanMEDS Roles” that describe a modern, competent physician. These Roles include: Medical Expert (central Role), Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional. The CanMEDS competencies have been integrated into the Royal College's accreditation standards, objectives of training, final in-training evaluations, exam blueprints, and the Maintenance of Certificate program.

Fundamentally, CanMEDS is an initiative to guide medical educators and practising physicians to meet evolving societal and patient needs. The focus of CanMEDS is on articulating a comprehensive definition of the competencies needed for effective practice. Today, the CanMEDS physician competency framework is being adopted and adapted by other professions, including family medicine, as well as in many other jurisdictions around the world (e.g. United States, United Kingdom, Denmark, Netherlands, New Zealand and Australia).

Tools are available, and more are being developed, to assist medical educators and praticising physicians who want to teach, assess or enhance core skills such as interprofessionalism, collaboration, communication, ethics, advocacy, etc.

There is an ongoing dialogue between the two Colleges about the relationships between the four principles and the CanMEDS competency framework.

For more information, please contact us today at canmeds@rcpsc.edu or visit our website at http://rcpsc.medical.org

THE FOUR PRINCIPLES
by Dr. Paul Rainsberry, Associate Executive Director, Academic Family Medicine, The College of Family Physicians of Canada

The Four Principles of Family Medicine are over 20 years old having been first formulated by a working group on postgraduate family medicine curriculum in 1985. Their definitions have been rewritten a couple of times since then but the fundamental concepts underlying them have not changed. They were intended to provide a framework to justify some significant changes to family medicine curriculum but they have proven to be a rich guide to the practice and teaching of family medicine ever since. Now they are integrated into and guide not only curriculum design but also our accreditation and certification processes.

The principles were unique in their time because they focused not just on the need for strong clinical skills and judgment but on things like context of practice, communication and relationships and a spirit of inquiry and self-assessment. More recently we have seen other specialties struggle with some of the same issues and projects such as Educating Future Physicians for Ontario (EFPO) and the CanMEDS project have been attempts to include these kinds of elements more explicitly in both undergraduate and postgraduate education. The College of Family Physicians has been challenged by these new models to adapt to them and integrate our principles into the roles defined by CanMEDS. It is a useful project but we must not forget that there is a difference between CanMEDS and the Four Principles. It is perhaps best defined by Ian McWhinney’s distinction between roles and principles in his own ‘Textbook of Family Medicine.’ Ian suggests that members of a clinical discipline are defined by what they “do” more than by what they “know”. What clinicians do, their ‘role’, is really an outcome of their worldview, their values and principles. This is not an insignificant distinction; family physicians as a group, represent a distinctive worldview- a system of values and an approach to problems- that is different from other disciplines. If we are to preserve the four principles in the face of the new emphasis on roles in medical education we may need to redefine our principles to more clearly state our worldview and values. It is a project very much worth doing.

EXCITING INITIATIVES IN UNDERGRADUATE EDUCATION
by Meredith McKague, MD, CCFP, Undergraduate Program Directors Representative to the SOT Executive, Saskatoon SK

The past year has been a stimulating and fruitful one for Family Medicine teachers as we consider our role as undergraduate educators. Numerous exciting initiatives are occurring in undergraduate education; I will highlight just a few that have national significance.

The Enhancing The Role Of Family Medicine In The Undergraduate Medical School Curriculum Project was funded by Health Canada through the Health & Human Resources Department from April 1, 2006 to March 31 2006. This project’s primary objective has been “to identify strategies and actions to help strengthen the role of Family Medicine and family physician teachers, mentors and role models in the undergraduate curriculum of all Canadian medical schools, resulting in increasing numbers of graduation students selecting family medicine as their career of choice”. A strategic planning meeting held in April 2005 set out several goals for the discipline related to undergraduate education. Dr. Fraser Brenneis (University of Alberta) was enlisted to coordinate the year-long project. A few of the activities of this project have included extensive stakeholder consultations; a scan of the current Canadian medical school undergraduate admissions policies, curricula, and resources related to Family Medicine presence in undergraduate medical education; and the establishment of an Undergraduate Office at the CFPC with a mandate to coordinate materials and activities related to UG education. A final report will include recommendations for sustained actions to further enhance Family Medicine’s critical role in the education of undergraduate students.

A second joint project of Health Canada and the CFPC has focused on the role of Family Medicine Interest Groups (FMIGs) in educating undergraduate students about Family Medicine, promoting Family Medicine as a career choice, and providing opportunities to link undergraduate students with family physician role models. The program has provided funding that has allowed all seventeen medical schools to create or expand their own FMIGs. Through two national meetings of students and faculty leaders, the project has also created infrastructure for the ongoing development and support of FMIGs across the country. The CFPC is working with government at various levels to ensure the sustainability of FMIG activities.

Another key initiative in UG education has been the development of a document entitled National Undergraduate Family Medicine Learning Goals and Objectives. Authored by Ian Scott, Cathy MacLean and Risa Freeman and developed with input from the National Undergraduate Program Directors and the Section of Teachers, this document was recently endorsed by the CFPC Board. It outlines curriculum content relevant to Family Medicine and will prove a valuable tool to undergraduate curriculum planners. Contact ug_learningobjectives@cfpc.ca to request a copy.

Also new in 2005, The CFPC Medical Student Scholarship Program recognizes outstanding students who have demonstrated an interest in and/or commitment to family medicine and further highlights our discipline at each medical school.

These are just a few of the many initiatives currently ongoing to promote Family Medicine in undergraduate education. While these programs are driven, at least in part, by the practical need to ensure adequate numbers of new physicians entering our discipline, their potential benefits go far beyond recruitment alone. Family Medicine teachers can and do positively influence medical students (both generalist and specialty-bound) to become more compassionate, effective, patient-centered practitioners. Our active involvement in our medical schools’ recruitment, admissions and curriculum planning processes help our institutions to better recognize and respond to community needs. And our contact with enthusiastic undergraduate students often refreshes us and rekindles our excitement as teachers.

1. Ivy Oandasan, Presentation: ‘Enhancing The Role of Family Medicine In The Undergraduate Medical School Curriculum’ at SOT Executive meeting, May 15, 2006.

GLOBALLY SPEAKING: A NORTH AMERICAN INITIATIVE TO INCREASE JAPANESE STUDENT INTEREST IN FAMILY MEDICINE
by Eric Cadesky, MD, CM (Resident PGY2), McGill University. Hisayuki Hamada, MD, PhD, National Hospital Organization, Nagasaki Medical Centre, Nagasaki, Japan. Manabu Yoshimura, MD, Japanese Association for Development of Community Medicine, Ibi Community Medical Centre, Gifu, Japan.

The Japanese healthcare system is being reformed to emphasize Family Medicine. However, medical students are not choosing careers in Family Medicine. Interestingly, many of the challenges facing student interest in Family Medicine in Japan are similar to those in North America: poor exposure to Family Medicine role models, unawareness of the opportunities in family practice, and an obscured identity of Family Medicine.

One of the solutions from North America has been the creation of Family Medicine Interest Groups (FMIGs.) Given that student interest in Family Medicine in North America and Japan has the same challenges, we theorized that a successful initiative from North America—the Family Medicine Interest Group—could also work in Japan. Our goal was to begin the process of implementing FMIGs in Japan. Specifically we set out to a) raise awareness about FMIGs; b) endow leaders with the skills of how to form a group; and, c) motivate and instil confidence to start a FMIG at their home institutions.

Participants were voluntary attendees of a workshop given on three occasions by one of the authors (EC): twice at the 2005Asia Pacific World Conference of Family Doctors in Kyoto and once for members of the Japanese Association for Development of Community Medicine in Tokyo. The interactive workshop was designed for many levels of experience: students, residents, and staff. It began with a PowerPoint Presentation created by one of the authors (EC); the presentation highlighted the history and current state of Family Medicine in Japan and abroad and included the example of the McGill University FMIG model. The audience was then divided into smaller groups and each group was assigned specific questions to answer concerning various aspects of starting a FMIG. The audience then reconvened and answers were discussed amongst the entire group. At the end of the workshop, participants were asked to complete and return an open-ended evaluation (“Were you satisfied with this workshop? Please provide comments.”)

40 students, residents, and staff attended the workshops. All participants submitted their comments.

All participants stated that they were satisfied with the workshop. Despite not specifically asking participants about their level of awareness, most participants volunteered that they were now better informed of the local and global challenges facing Family Medicine. Further, although many recognized the work ahead, most participants reported that they were eager to start FMIGs at their home institution; 30 (75%) stated that they now had the skills to start such groups and 26 (65%) reported that would be confident starting a group. Several participants commented that their skill level and confidence were particularly increased as a result of having already thought through the details by way of concrete examples in the workshop.

As with most places in the world, Japan is in need of strong Family Medicine to care for the population. In order to accomplish that feat, student interest in Family Medicine must overcome many systemic obstacles within medical education. In North America, Family Medicine Interest Groups have played a large role towards this goal.

Our study has shown that a short, inexpensive, well-planned intervention from North America can increase medical leaders’ awareness of the challenges facing Family Medicine and that this intervention can also increase self-perceived skill and confidence levels to start a Family Medicine Interest Group.

References

1) World Health Organization. World Health Report 2000. http://www.who.int/whr/2000/en/whr00_annex_en.pdf Accessed July 2 2005.

2) Organisation for Economic Co-operation and Development Health Care Reform in Japan. http://www.oecd.org/LongAbstract/0,2546,en_2649_201185_1848604_1_1_1_1,00.html Accessed July 2, 2005.

3) Ohtaki J, Fujisaki K, Terasaki H et al. Special choice and understanding of primary care among Japanese medical students. Med Edu; 1996; 30: 378-84.

4) Cadesky E. One year later: My personal and professional journey in starting a family medicine student interest group. Canadian Family Physician 2005; 51: 918-921.

5) http://www.wonca2005.jp/index.html

6) Cadesky E, Wong, E, Leyenaar L, Vogt K. Family Medicine Interest Groups: A Student-Driven Initiative to Cultivate Interest in Family Medicine Career. Workshop presented at the Family Medicine Forum, Toronto, Canada on November 25th, 2004.

HOUSE CALLS – AN NFB DOCUMENTARY FILM
by Mark Nowaczynski, PhD, MD, CCFP, FCFP.

When we are old we become invisible. We lose our health. We lose our mobility. We lose our independence. We are institutionalized or become house-bound and retreat into our homes, disappearing into a forgotten and hidden world.

As a family practice resident I was exposed to home visits, and this undoubtedly influenced my subsequent practice patterns. Making home visits is a desirable component of the family medicine curriculum for all family practice residents in Canada. How can we expect Canadian doctors to provide home-based care if they are not exposed to it during their training?

The practice of medicine has changed dramatically since WW II. According to an article in the November 2004 NEJM, in the 1930’s 40% of all doctor-patient encounters were house calls. By 1980 the proportion had dwindled to a mere 0.6% and it continued to drop through the 1990’s despite the rapid expansion of the home care sector. Today home care is the fastest growing health care sector.

The medical community is far too disconnected from the home care sector, and the confusing and uncoordinated fragmentation of service delivery leaves patients and caregivers lost in a forest of organizational silos. This is confusing and frustrating for patients, caregivers, and physicians, and it is far from being patient centered.

The majority of the one million Canadians over the age of 80 will live out their days at home. The 80+ age group is the fastest growing segment of the Canadian population. If health care is to be shifted into the community, it must be accompanied by the provision of adequate and cost effective medical and supportive services for those who are currently receiving little or no care in their homes.

How does one go about stimulating change?

Photography has a venerable history as a tool for social change. In 1998, I began to photograph my house-bound patients in order to document this significant social issue and to illustrate the pressing need for change. Increasing awareness about the growing home care crisis is a critical step on the road to sustainable solutions, and photography provides a powerful tool for this advocacy.

Though a work in progress, this photo-documentary has been profiled in national print, radio, and television media. This approach to photographic advocacy has touched a nerve. This project is now the subject of the recently completed National Film Board of Canada 55 minute documentary film, “House Calls” (www.nfb.ca/housecalls). As described by director Ian McLeod: "This NFB documentary is examining how Dr. Mark Nowaczynski is struggling to improve our home care delivery system so he can care for the frail elderly patients who desperately need him. His calling cards to effect change are the photos he takes of them. In the course of this film we follow Mark as he tries to make a difference. We see how he combines his passion for photography with his commitment to improve the lives of his patients. The film is designed to be like one of Mark’s photographs – an artistically powerful work in its own right, and useful in creating social change."

“House Calls” is now available from the NFB at www.nfb.ca/housecalls. The NFB made this film to be used as a tool for advocacy. I think that it is a wonderful film. “House Calls” won a Freddie Award in Caregiving at the International Health & Medical Media Awards in New York City on November 4th.

Editor’s Note - House Calls – An orientation to Homecare

I have been using the NFB documentary film “House Calls” in our resident training program at McGill. I show the 55 minute film as part of an orientation to Homecare training. It is a visually and viscerally engaging film that keeps the residents focused on the many medical/social/ethical issues of our frail homebound patients. The discussion after the film is always lively and heated as it brings out problems that are often difficult and controversial for the residents. The film gives the residents a chance to see (for some it’s a first) a real Canadian doctor visiting patients at home. Aside from the positive doctor role-modeling, it also mentors how one person can follow his creative passion to foster social change.

It’s difficult to make care of the frail elderly a sexy topic for our trainees, but this documentary does it.

TO GO WHERE NO CLINICAL CLERK HAS GONE BEFORE - A SURPRISING WAY TO INITIATE MEDICAL STUDENTS TO HOUSE CALLS
by Steve DiTommaso, MD, CCFP, FCFP, Université de Montréal

The CLSC des Faubourgs, one of 12 teaching sites in family medicine at the University of Montréal, receives one or two clinical clerks every month for the compulsory undergraduate rotation in family medicine. They attend various clinical activities at the CLSC including booked patients ("office"), our walk-in clinic, a perinatality clinic, guided readings, and courses.

Generally, medical students are often relegated to observational roles. They tend to do time-consuming, low-risk activities (attending ward rounds, doing histories and physicals, etc), and they are less involved in high-risk activities (i.e., procedural skills) and more complex activities (i.e., counseling, home care).

Few medical schools involve students actively in home care. During the first two years that this author "taught" house calls to medical students, he simply brought them along with him to visit selected house-bound patients. The author despaired as his students appeared bored and disinterested, despite enticements to involve them more actively during house calls: to do parts of the physical exam, to ask patients questions, to do Mini-mental exams, etc.

Then one day the author cracked!

As before, each medical student is scheduled for a morning of “house calls with Dr DiTommaso”, of which he or she is told little in advance. However, since August 2004, they are now told to unlock the door to my office at 0900h a.m. in order to find a “surprise” which awaits them.

The medical student then discovers a black medical bag, a green tote-bag containing a patient’s medical chart and blank forms, and an envelope containing a “special mission”. The special mission directs them to proceed forthwith to the home of a new patient in order to perform an evaluation of their health status, as well an appraisal of the resources which allow the patient to cope with their disabilities.

The students are told that I will arrive at the patient’s home around 1100h in order to review his/her findings and to verify essential components of the history and physical. The student and I then return to the family practice unit to discuss the case, to complete the chart, to contact pharmacies or family members, to order investigations, etc. When the patient sees their new family doctor in the weeks that follow, our note, lab results, chart summaries from other hospitals, etc will all be available by then.

I “borrow” new patients, of which little is known, who have been referred to our CLSC, and who have floated up to the top of our waiting list, on the verge of being taken charge of by one of our 15 very busy family doctors. The medical student will perform the initial evaluation on this new patient alone. The patients will eventually be taken over by the regular doctor who would have seen them anyway (thus the term “borrow”).

• Students find the activity very stimulating. They are excited and nervous; they enjoy the challenge and the sense of danger. They almost universally compliment the “unusual” nature of this activity.
• Students are forced to think their way through unexpected problems that the professor had solved for them previously.
• Students are faced with surprising disease states and social situations that they must evaluate without help (initially).
• Students are forced to contemplate the various community and professional services which exist to help disabled or sick patients remain in their homes as long as possible.

Disadvantages of the “Special Mission” Model

• There is a lack of continuity of care for the student due to the short duration of the rotation (one month). Our medical students may never see the same patient for a second time.
• Potentially, some students could be destabilized by the unconventionality or perceived danger of the situation. In fact, one physician doing a remedial rotation at our unit did freeze before starting off on his mission, and half way through the house call he “aborted mission” and left the staff physician alone to complete the physical exam. (This individual had known but under-estimated psychological problems.)
• There is always the potential for real danger to the students in our impoverished urban environment, although patients are selected as carefully as possible. Sometimes we know very little about the patients when they are referred to us.
• Some students get lost on their way to patients’ homes, despite the maps that may or may be left out for them.
• Some family situations are complex for medical students. In one case the son of the elderly patient was actively suicidal (it turned out that this was the reason he had asked our CLSC to relocate his mother!), and the learner was so distracted by the son’s health problems to that he forgot to evaluate the patient. In another case, we sent two medical students (who went as a pair, exceptionally) to evaluate an elderly patient dying of peritoneal carcinomatosis, and they were harangued by her bizarre daughter who had already spent over $10,000 on herbal remedies and who spent most of the house call criticizing the excellent oncology team who was administering her mother’s palliative chemotherapy. None of these kinds of situations could be anticipated. However, what better way to demonstrate the true nature of family medicine? Most medical students have done remarkably well and left the activity with a new understanding of human behaviour.
• There is no formal teaching, prescribed readings, or preparation for this activity. Should there be? Cases are discussed at the end of the half-day, depending on the clinical material which is uncovered.
• There have been several “snafus”. One medical student was too intimidated to enter my office. One medical student was joined unexpectedly at 900 AM by an unstable physician who was on a remedial rotation at our unit (and who should not have shown up that day) – this physician spent 20 minutes warning the medical student of the extreme physical danger of home care before being intercepted by two staff physicians who luckily overheard him! On two occasions I forgot to leave the “special missions” in plain view on my desk when obstetrical deliveries impeded me from coming in the day before, and the medical students eventually wandered out to our secretary who paged me so I could solve the problem.
• The activity is sometimes confusing to the 12 social workers, 20 nurses, and 6 occupational therapists who act as case managers for home care patients. They sometimes call me and leave me messages long after I have transferred patients to their new family doctors, thinking that I have taken them on myself (perhaps because my name appears on their pill bottles?).
• I end up absorbing a few more new home care patients than I would otherwise. For example, in one case a patient was to have been assigned to a colleague after I had “borrowed” the patient from the waiting list. I agreed to care for the patient temporarily as she was expected to be relocated to a nursing home within days. However, she was relocated to a community resource near my office and I ended up keeping the patient. Such exceptions do crop up now and again.
• This kind of activity is dependant on a rich supply of fresh, unknown patients, as well as on a medical team which has the capacity to absorb so many new patients after the student has evaluated them. (Note that we also allocate 3 or more new home care patients per year to every R1 and R2). Our CLSC is fortunate to have such a well-developed home care team.

Representatives of eight medical schools attended the sessions. Guests during the day were Dr. Cal Gutkin, Dr. Alain Pavilanis, Dr. Michael Malus, Ms. Lynn Dunikowski from the College Library, as well as representatives of the Northern Ontario School of Medicine.

John Edworthy and Eva Knell presented “What is Faculty Development: Changing Times, Changing Definitions?” The need and importance of sustaining teachers in our present health care environment was emphasized. Lively discussion about the ways and means of doing this and possible approaches included appropriate remuneration, benefits of faculty appointments, inclusiveness as members of the teaching community, regular meetings, mentoring programs, and other means of networking.

“The Happiness Factor” was discussed. If happiness is at one end of the continuum, being overwhelmed is the other side; challenges that are presented along the spectrum in between need to be a focus in promoting “The Happiness Factor” within our teachers. Promoting a culture of enthusiasm may be beneficial.

Dr. Cheri Bethune led a discussion about “Rural and Urban Faculty Development”. Possible approaches included site visits, use of PDA’s for distance education, and the potential of having “Reverse Faculty Development”.

Dr. Rod Andrew presented “International Medical Graduate: What Are the Faculty Development Issues?” He emphasized the need for diagnosing problems early; for having an in-depth orientation program, and for learning the stories of the International Medical Graduates.

A presentation on “Ethics Teaching” was given by Dr. Michael Malus. He informed the group that policy was being developed concerning interactions and relationships with drug companies. He also alerted the group about the existence of teaching resources regarding ethics, which are available on the College website.

Lynn Dunikowski presented “The Canadian Physician Library”. She informed the group that Library Services include 5 free literature searches, and 25 articles per year for members of the College of Family Physicians. She also pointed out online Faculty Development material, which is found under “F” in the College “A-Z” index.

General discussion also included the function of the Section of Teachers Faculty Development Group. During the discussion, potential approaches identified were: -using part of a day at FMF that would be dedicated to Faculty Development

• having the Section’s sessions be bilingual in nature
• the importance of developing a core group of Faculty Development Basics Workshops, possibly presenting these on a regular basis at FMF
• scholarships, modeling mentorships, passport to show past Faculty Development Review workshops
• program evaluation rigor as part of our requirements
• the need to develop and disseminate presentations from past workshops and Faculty Development basics
• the importance of the opportunities provided by the cross
• country check-up as a way to share ideas
• innovations and developments in Faculty Development
  

Over the past few years, educational programs across the country have been increasingly active in providing retraining and re-entry positions for the many internationally educated physicians already living in Canada. Because programs, IMGs, and teachers themselves have identified a need for teaching tools and skills for teachers focused on the needs of international graduates, The Association of Faculties of Medicine of Canada has produced a Faculty Development Program for Teachers of International Medical Graduates, funded by Health Canada, under the leadership of Yvonne Steinert and Allyn Walsh.

The program consists of a series of easy-to-use modules on six different topics, each containing a pertinent literature review, suggestions for effective teaching, and detailed directions for mounting faculty development workshops and activities. Educational tools and materials, including PowerPoint slides and videos, are also included, as are faculty development guidelines for conducting site-specific activities. Modules can be used independently of one another; however, they are also designed to fit together into an overall ongoing faculty development program. While the materials are designed to be implemented with a group of teachers, instructions for using them in independent study by a single teacher are also included.

The modules will very soon be available on the AFMC website http://www.afmc.ca/img/index.html and hard copies of the modules, including CDs with the slides and videos, will be sent to each university postgraduate office, faculty development office and to IMG programs across the country this summer. The modules will be available in both French and English.

The titles of the modules are as follows:

Educating For Cultural Awareness Authors:
Patricia Thille MA, Blye Frank PhD (Dalhousie University)

Orienting Teachers and IMGS
Authors: Heather Armson MD, Rod Crutcher MD (University of Calgary)

Working with IMGs: Assessing Learner Needs and Designing Individually Tailored Teaching Programs
Authors: Allyn Walsh MD (McMaster University) and Yvonne Steinert PhD (McGill University)

Working with IMGs: Delivering Effective Feedback
Author: Allyn Walsh MD (McMaster University)

Working with IMGs: Patient-Centred Care and Communication
Author: Nancy Fowler MD (McMaster University)

Working with IMGs: Untangling the Web of Clinical Skills Assessment
Author: Lynn Russell MD (University of Toronto)

This Faculty Development Program for Teachers of International Medical Graduate provides materials in such a way that educational programs will be able to mount successful faculty development activities for their teachers. Indeed, although the program is designed to enhance the teaching of IMGs, the teaching of all learners is likely to benefit.

Section Of Teachers Executive

sot@cfpc.ca 

Dr. Ivy Oandasan (Chair)  

Dr. Vonda Hayes

Dr. Wanda Parsons   

Dr. Jean Warneboldt

Dr. Meredith McKague    

Dr. Liz Shaw

Docteur François Lehmann 

Ms. Sue Berry

Dr. Maureen Rappaport

Dr. Eva Knell