Renewing postgraduate family medicine education: the rationale for Triple C

Background

Family medicine residency training in Canada is internationally recognized for its 17 universities offering broad-based training programs that produce more than 1000 graduates each year. These graduates are recognized as well-qualified family physicians and are able to secure clinical and academic positions locally, nationally, and beyond.

At the same time, family medicine residency programs are increasingly challenged to provide the necessary education to residents for this broad-based clinical discipline. Innovation is necessary in order to respond to the following:

• the need for increased efficiency in family medicine training,

• a demand for social accountability in postgraduate residency programs, and

• a move toward competency-based education.

Increasing efficiency

Our medical system often seems to value depth over breadth of knowledge. Family medicine education programs have been developed from the tradition of the rotating internship and, as a result, our residents can spend a considerable amount of time on rotations that are more about tradition and noneducational service than education.

The members of the CFPC’s Section of Residents have expressed concern about their training. The Section maintains and regularly reviews the Guide for Improvement of Family Medicine Training,³ a document that details residents’ perspectives on their training programs and makes recommendations for enhancement. This document reveals that residents across Canada believe their training is, at times, too highly focused and provided in contexts that are not relevant to their future family practices.³ Perhaps related, many family medicine graduates do not enter comprehensive practices.

There is a need to move to more efficient and effective programs with a curriculum centred firmly in family medicine and aimed at its practitioners. Such programs must be designed from the start to meet the goal of producing competent family physicians who provide comprehensive care.

Social accountability

All educational programs must adapt constantly to meet the changing demands of society and health care systems. Primary health care is changing; the population and its health needs are changing; and stakeholders’ expectations are changing. Family medicine as a discipline has become increasingly mature in the past 5 decades, with well-defined parameters and a sophisticated research base. Furthermore, our knowledge of what is educationally effective continues to advance. The Future of Medical Education in Canada project outlined the importance of linking training to community needs, learning in community contexts, exposure to intraprofessionalism and interprofessionalism, the use of a competency-based approach to education, and the importance of generalism.⁴

The Association of Faculties of Medicine of Canada adopted the World Health Organization’s statement on social accountability: “[Medical schools have] 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.”⁵

We are accountable to both the public and the government for the quality and consistency of practice in graduates of our family medicine education programs. We must ensure that we are providing a renewable curriculum for training in our discipline, which not only adapts to change but also anticipates it.

Competency-based education

Research in medical education has thrived and continually produces guidance on effective methods of training, which must be taken into account as training programs move beyond their ancient apprenticeship models. Globally, competency-based educational systems have gained increasing prevalence as programs seek methods that are more accountable and strive to ensure specific outcomes for their graduates.

Canadian residency programs and the CFPC are challenged by many stakeholders to change both curricular content and educational strategies. The learners in our system rightly expect the best and most appropriate education that is designed to produce the best possible family physicians who are prepared to adapt to this dynamic environment. Findings and strategies from current research on effective learning, as well as new technologies and instructional innovations, must be considered in curriculum design.

Expertise requires repeated, deliberate practice,⁶ and most of the deep learning must take place in the clinical context relevant to future practice. If our future family physicians are to develop not only routine expertise but also the adaptive expertise necessary for the highest quality of medical care, their training must be community based and provide sufficient appropriate hospital experience to render them capable of providing comprehensive care—the goal of family medicine training.

Family medicine curricula should be intentionally designed to allow the resident to attain the desired family medicine competencies. It should seek learning experiences that will provide the proper setting to allow residents to attain these competencies, and the evaluation systems developed should assess these competencies specifically.

Conclusion

Triple C is Canada’s curriculum for family medicine. This new curriculum was developed in response to the call for efficient, relevant training to meet Canada’s changing social needs, and is based on providing competency-based education. The next 3 articles will highlight each C in Triple C in more depth. Look for the next installment, which will further discuss continuity of education and patient care. Have questions? Visit www.cfpc.ca/triple_C or contact triplec{at}cfpc.ca for more information.