A new way forward via innovative integration

Further evaluation of integrated postgraduate training needed

Residents have offered varied reasons for pursuing ES training that cut across perceived community health care needs, career aspirations, focused clinical interests, and management of work-life demands.⁶ Data collected by the CFPC through the Family Medicine Longitudinal Survey have shown year-over-year increases at our institution, the University of Toronto in Ontario, in the number of family medicine residents choosing to apply to ES programs, with 47% of residents in our 2018-2019 cohort applying for additional training. This data set revealed that most residents felt adequately prepared to practise in their ES area of interest after graduation; however, 26% felt prospective employers would require this training, and 42% wanted even more exposure to the ES program, despite feeling prepared to practise in that area. According to Grierson et al, some ES program residents express keen interests in higher-acuity clinical care, while others seek to improve their competitiveness for academic positions, and still others seek to optimize their remuneration and work-life balance.⁶ There are also hidden curriculum messages that emerge throughout training that make family medicine residents feel that completing an ES program is valued or even necessary to secure work in urban centres.^8,9

Interest in ES training programs has spurred broader explorations of whether Canadian family medicine residency programs should move to a 3-year training model, to align with programs internationally where training is 3 to 4 years in length.¹⁰ Consideration of this option arose when the CFPC launched multiple initiatives to evaluate the future of family medicine training programs.^10,11 These included publishing the Family Medicine Professional Profile, which defines the scope of care of family physicians,¹⁰ and developing the Outcomes of Training project, which re-examines the nature of family medicine residency training in Canada.¹¹ These initiatives provide a framework for outgoing competencies, length of training, and readiness to practise comprehensive family medicine in diverse community settings.^10,11

The possibility of transitioning to a 3-year family medicine training program creates a unique opportunity to bridge the diversity of and interest in ES programs with the potentially shifting landscape of family medicine residency. An innovative approach could involve integrating existing ES programs within traditional residency programs. As a curricular strategy, integration aims to co-locate learning either longitudinally or across subject matter areas to support the development of adaptive expertise.¹² Program-level, longitudinal integration would mean that ES training is interwoven with and across an expanded family medicine residency program.¹³ This integrated approach could maintain ongoing focus on comprehensive care and professional identity formation in primary care while simultaneously developing focused skill sets. Curricular integration is commonly explored in the undergraduate medical context, with the main aim of integrating basic and clinical sciences.¹³ However, there is scant empirical attention paid to integration in postgraduate programming.^13-15 We suggest that integrated postgraduate programs should be evaluated more closely, with a targeted exploration of the potential for sustainable upscaling.

In Canada, there are only 3 programs that are formally structured and promoted as longitudinally integrated ES family medicine residencies: the integrated family medicine–emergency medicine program at Dalhousie University in Halifax, Nova Scotia, the family medicine–care of the elderly program at the University of Manitoba in Winnipeg, and the University of Toronto’s newly introduced program in the Department of Family and Community Medicine.^16,17 The Family Medicine and Enhanced Skills (FAM-ES) Program at the University of Toronto is a 3-year, longitudinal curriculum that integrates content from an existing ES program with core family medicine content during years 2 and 3 of training. The first FAM-ES cohort integrates existing care of the elderly and palliative care programs. Internal recruitment for the pilot program began in early 2020, with 2 FAM-ES residents beginning their integrated program in September 2020. Several key principles underpin FAME-ES: it maintains an ongoing focus on comprehensive care while training residents to meet more targeted community-care needs, it emphasizes team-based family practice, and it supports residents’ professional identity formation as comprehensive family physicians. Successful enactment of these principles will require resource investment, faculty commitment, and purposeful evaluative research to inform ongoing and future programming.

It is problematic that there is limited scholarly inquiry regarding the implementation and impact of ES programs. The current scholarly interest in the changing practice patterns in Canadian primary care will undoubtedly be relevant to understanding the broader outcomes of ES programs.^6,18 Such inquiries can allow the field to examine whether these programs are instrumental in increasing the number of family physicians in comprehensive practice or whether they limit access to comprehensive primary care. It is also essential that evaluative scholarship attends to quality, feasibility, and sustainability issues concerning the implementation of such programs. The outcomes of ES and integrated ES programs might vary over time and depend on context, owing to differences in program-level principles, pedagogies, teaching practices, and experiential opportunities. If the integrated ES programs are to become a model for 3-year family medicine residency programs, attention to program implementation is critical, given the existing evidence about the elusiveness of sustained, scaled-up curricular reform.^19-21 Innovative or reformative curriculum interventions are rarely implemented exactly as prescribed.^22,23 Not only can curriculum change be hotly contested, but adaptation is also often necessary to modify planned curricular strategies for emerging learner needs and contextual variations.²⁴

The evaluation of program implementation needs to include an examination of whether and how core reform principles are enacted and how or why curricula evolve over time. For the evaluation of the FAM-ES program specifically, we draw on an innovative framework for evaluating implementation that guides the examination of how espoused pedagogic principles are enacted in practice.²⁵ Our evaluative work will examine how teaching and learning practices promote or demote core curricular principles. Additionally, it will explore questions about the program’s sustainability (eg, examining whether faculty and learners are structurally and individually positioned to enact prioritized program principles). The insight gained from such explorations can be instrumental for educational systems working to mobilize scarce resources or scale up pilot interventions locally, regionally, or nationally.²⁵ Failure to identify implementation challenges can cast doubt on the accumulated knowledge about how or why integrated ES programs will influence varying outcomes. We contend that alongside program design and delivery considerations, longitudinally integrated ES programs must evaluate their feasibility and sustainability to inform future family medicine education meaningfully. Such evaluative work is particularly essential when there is limited evidence pertaining to competency-based medical education in the literature.²⁶ This work is critical not only to ongoing program refinement but also to facilitating the optimal design of a summative evaluation strategy to capture longer-term program outcomes—both the planned and the unanticipated.