Overview

COMPETENCY-BASED EDUCATION IN FAMILY MEDICINE

 

“The Sine Que Non of family medicine is the knowledge and skill that allows a physician to confront relatively large numbers of unselected patients with unselected conditions and carry on a therapeutic relationship over time… The skill of patient management is the quintessential skill of clinical practice and the area of knowledge unique to the family physician “. 1 (G. Gayle Stephens, 1982)  

Family Medicine is a comprehensive, generalist discipline that provides high quality primary health care.  Strong primary care has unequivocally been shown to be at the core of effective and efficient health care systems 2,3,4,5 The health of a population, including all-cause mortality, is independently and most consistently associated with the region’s family physician to population ratio. 6 In the Canadian setting, Family Medicine is the most common access point to health care for patients. As such, family medicine is the central medical discipline.  Family physicians are expert in dealing with uncertainty, undifferentiated presentations and the complex interplay of biological, personal and societal factors in health and illness.  Judicious use of investigations, responsible stewardship of health care resources and thoughtful application of research findings to the general population are some of the main characteristics that distinguish the specialty of Family Medicine. As physicians of persons (rather than of specific diseases or body parts) family physicians provide longitudinal care through healing relationships over time.  


Family Medicine has a unique body of knowledge and skills within the practice of medicine. It is a discipline focussed on common diseases, reaching across organ systems and life cycle stages and utilizing a prevalence- based approach.  In a given population family physicians are aware of the common diseases in that population. They become skilled in the diagnosis and treatment of the diseases seen within their context of practice; they are in essence the “surgical arm of Epidemiology”.7

The training of family physicians, therefore, must be grounded in Family Medicine. The skills that a family physician must possess 8,9 include:

A)   Practicing preventive medicine
B)   Differentiating presentation of common self-limiting illnesses from presentation of acute life-threatening problems.
C)   Managing common acute conditions.
D)   Managing chronic disease including those significantly influenced by patient personality and other co-morbid mental health issues.
E)    Working with the uncertainty inherent in undifferentiated problems
F)    Practicing procedural skills relevant to the discipline  

 

Postgraduate Training in Family Medicine:  

“A skilled family physician is an efficient and effective problem-solver and decision-maker. One of his/ her greatest potential contributions to medical education is the teaching of these skills. .Students should be taught to make clinical decisions in the way they are made by experienced clinicians [and] should be taught the theory of diagnosis.”
10(McWhinney, 1972)

 

Being the personal physician to a patient is a great privilege bestowed upon the family physician by society. Residents must complete their postgraduate medical training with the necessary knowledge, skills, attitudes and behaviours to provide high quality comprehensive and compassionate care to the people of Canada. The College of Family Physicians of Canada (CFPC) has adopted a competency approach to the accreditation of training of family physicians in Canada. The model is referred to as the CanMEDS-FM framework, which is modified from the CanMEDS model of the Royal College of Physicians and Surgeons of Canada (RCPSC).

 

In response to the change in accreditation standards in Family Medicine, the Department of Family and Community Medicine at the University of Toronto has developed a novel competency-based curriculum which is mapped to the CanMEDS- FM framework.  The curriculum is Family Medicine centred. With this new curriculum, the competencies required to be an effective family physician permeate through all the learning experiences encountered in residency. Attention to context and flexibility of approach is emphasized, such that these skills can be transferred from one population to the next and from one practice setting to another.

 

This document is a guide to the development of specific and necessary competencies, all of which are critical for a resident’s development as a competent physician.  It is not, however, a prescription of competence in all circumstances for competence is not a generic or static state of being. Instead, competence is dynamic, complex, context-dependent, and often team, system or organization-based.  Nevertheless, for individual learners this competency-based approach provides a clear guide to necessary behaviours, skills, knowledge and practices that will enable their development over time into a compassionate, comprehensive and competent family physician.   

The training in Family Medicine is organized in terms of competencies a family physician must possess to deal with patients in:
A)
   Different stages of the life cycle
i)   Maternity
ii)  Childhood and Adolescence
iii) Women’s Health
iv)  Men’s Health
v)  Care of Elderly
vi)  End of Life Care
B) Different Practice Environments
i) Office
ii) Emergency room
iii) In- hospital
iv) Long- term care
v)  Home
vi) Community
vii) Global    

 

How to Use this Document:

The Family Medicine competencies will serve as the anchor for all learning experiences in the program. Things that are common amongst particular populations (such as children and adolescents, pregnant women, elderly and palliative care patients) or common in different settings (such as hospital care or emergency medicine) can all be categorized into one of the six clinical categories. The specific content knowledge or procedural skills may differ when working with different populations and in different settings, but the clinical method for the generalist physician remains the same regardless of whom they are seeing or where they are seeing them.  

The document currently provides the Key Essential Competencies required of all trainees in the program. All key competencies are further defined by a set of enabling competencies. The Integrating Family Medicine page lists the generic competencies of the graduating practice-ready Family Physician. The key competencies are further grouped according to practice domain which will allow program directors and residents to develop rotation-specific learning outcomes. The Care of Adults domain incorporates general competencies in the provision of care to adults. However, there are links available within the document which may be used by both program directors and residents in planning specific rotations in Women’s Health, Musculoskeletal Medicine and Mental Health. Prior to beginning a learning experience or rotation, it would be helpful to review the competencies applicable to the experience and to develop a strategy for achieving them. Throughout the learning experience or rotation the competencies should be reviewed to ensure that they are being achieved.  

The development of this competency-based curriculum in Family Medicine has relied on the experience, wisdom, time and energy of faculty members representing all the distributed sites in the DFCM at the University of Toronto. We hope that the document will provide a meaningful and practical anchor for your learning during the residency.  

Best wishes,  
Karl Iglar M.D. C.C.F.P.
Cynthia Whitehead M.D. C.C.F.P.
Curtis Handford M.D. C.C.F.P  

References:


1. G. Gayle Stephens. The Intellectual Basis of Family Practice 1982. Winter Publishing Company.
2. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005; 83: 457-502.
3. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations’ health: assessing the evidence. Health Aff (Millwood). 2005: W5-97.
4. Starfield B. Refocusing the System, NEJM. 2008; 359 (20): 2087-2091
5. World Health Report 2008- Primary Health Care: Now more than ever. Geneva: World Health Organization, 2008.
6. Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. The Relationship between Primary Care, Income Inequality, and Mortality in US States, 1980-1995. JABFP. 2003; 16 (5): 412- 22.
7. Feldman P. The 5 C’s- A conceptual model for Family Medicine competencies (unpublished).
8. McWhinney IR. The Foundations of Family Medicine. Canadian Family Physician April 1969: 13-27.
9. Gayle Stephens G. The Intellectual Basis of Family Practice 1982. Winter Publishing Company.
10. McWhinney IR. Problem solving and decision-making in primary medical practice. Canadian Family Physician 1972: 109-114

Curriculum Committee

Faculty
Dr. Karl Iglar (Chair)
Dr. David Clarkson
Dr. Susan Glover Takahashi
Dr. Cynthia Whitehead

Residents
Dr. Ilana Greenwald
Dr. Karen Hershenfield
Dr. Judith Marshall
Dr. Ritika Goel
Dr. Sarah Warden


Competency Curriculum Authors

Competencies in Family Medicine
Dr. Curtis Handford
Dr. Perle Feldman
Dr. Nick Pimlott
Dr. Karl Iglar

Behavioural Competencies
Dr. William Watson
Dr. Pauline Pariser
Dr. Kingsley Watts
Ms. Maureen McGillivray
Ms. Lindsay Watson
Mr. Ian Waters

Domains of Practice

Maternity Care
Dr. Batya Grundland
Dr. Allegra Lywood
Dr. Teresa Killam
Dr. Karen Fleming
Dr. Susan Glover Takahashi

Care of Children and Adolescents
Dr. Susan Edwards, Karl Iglar

Women’s Health
Dr. Kymm Feldman
Dr. Sheila Dunn
Dr. Viola Antao
Dr. Dara Maker
Dr. Jordana Sheps
Dr. Praseedha Janakiram
Dr. Kerri Hetherington
Dr. Anita Lathia
Dr. Abeer Al Gasim

Care of the Elderly
Dr. Sid Feldman
Dr. Amy Freedman

End of Life Care
Dr. Jeff Myers
Dr. Christa Jeney

Emergency Medicine
Dr. Paul Hannam
Dr. Shirley Lee
Dr. George Porfiris 

In-Hospital Care
Dr. David Clarkson
Dr. Philip Ellison
Dr. Joyce Lee

Global Health
Dr. Katherine Rouleau

Musculoskeletal Medicine
Dr. Julia Alleyne

Mental Health
Dr. Scott Allan
Dr. Abbas Ghavam-Rassoul

Surgical Skills
Dr. Judith Marshall

Nutrition
Ms. Serena Beber
Ms. Kate Manchett 


Public Health
Dr. Bart Harvey

How to Use this Document

The document currently provides the Key Essential Competencies required of all trainees in the program. All key competencies are further defined by a set of enabling competencies. The Integrating Family Medicine page lists the generic competencies of the graduating practice-ready Family Physician. The key competencies are further grouped according to practice domain which will allow program directors and residents to develop rotation-specific learning outcomes. The Care of Adults domain incorporates general competencies in the provision of care to adults. However, there are links available within the document which may be used by both program directors and residents in planning specific rotations in Women’s Health, Musculoskeletal Medicine and Mental Health. Prior to beginning a learning experience or rotation, it would be helpful to review the competencies applicable to the experience and to develop a strategy for achieving them. Throughout the learning experience or rotation the competencies should be reviewed to ensure that they are being achieved.