Thanks to the farm team! The role of undergraduate family medicine educators in changing the landscape of family medicine

Introduction

In the late 1990s and early 2000s, family medicine decreased in popularity as a first choice of career for many Canadian medical students. The journey from the lowest point in 2003 to the increased 2020 match to family medicine (first iteration of the Canadian Resident Matching Service (CaRMS)) has been long and the result of efforts on many fronts (1). Among other influences, undergraduate curricula (formal, informal and hidden) are important in shaping student perceptions of family medicine and thus influencing their career choices(2). Undergraduate learning experiences are one factor influencing career choice. The Family Medicine Longitudinal Survey (FMLS) provides data with which we can evaluate the influence of undergraduate curricula (3).

Since 2010, family medicine residency programs, in collaboration with the College of Family Physicians of Canada, have been implementing the FMLS. At three time points (entry into residency, exit from residency and three years into practice), the FMLS explores residents’ perceptions of family medicine, their family medicine learning experiences and their practice intentions.The entry into residency FMLS survey provides insights into the kinds of family medicine (FM) role models and learning experiences our family medicine residents had during their undergraduate medical education. The current results demonstrate that residents entering into family medicine have consistently had good exposure to family medicine in their medical school training (Table 1 and 2). Across study years, it is heartening to see the high levels of undergraduate exposure offered to those entering into family medicine related to family medicine’s approach to continuity of care (78.9%-85.3%), comprehensive care (84.4%-86.5%) and complex undifferentiated problems (89.9%-92.0%).  These exceptional numbers reflect the work of family medicine teachers, preceptors and educational leaders in undergraduate medical education.  Family medicine residents who graduated from Canadian medical schools enter our FM residency training programs with a robust knowledge of what a family physician does (4).  The FMLS suggests that residents are matching into family medicine armed with an understanding that reflects the specialty of family medicine.  What contributed to this turn around?  An analogy from hockey suggests that we should look at the ‘farm team’ - the preceptors, educators and leaders responsible for teaching medical students.

The Establishment of the Farm Team

Beginning in the early 1990s, the CFPC substantially increased its support for undergraduate medical education. Under the leadership of then-CEO Cal Gutkin, the CFPC sponsored the first undergraduate family medicine program directors meetings in 1996.  Bob Woollard led the development of a team focusing national discussion on family medicine in the undergraduate curriculum(5). Two monographs (’02 and ’05)  outlined a national vision for undergraduate education in FM (6,7). From the work of these early leaders in FM undergraduate medical education, a diverse and committed group of undergraduate family medicine educators has provided continued strong leadership.  

The CFPC’s relationship with undergraduate family medicine education differs  from postgraduate education.  While the CFPC sets standards for postgraduate family medicine residency training programs, each Faculty of Medicine creates their own MD curriculum to meet undergraduate medical education  accreditation standards established through CACMS (Committee on Accreditation of Canadian Medical Schools).  Each undergraduate FM program director works within their own medical school and with their own faculty to contribute to the diverse educational goals of each school.  The CFPC provides support for undergraduate family medicine in two ways.  First, they provide support to the Canadian Undergraduate Education Directors in Family Medicine (CUFMED) group which includes undergraduate family medicine education leaders from all 17 Canadian medical schools.  Although this group is not a formal committee of the CFPC, meeting support enables committed leaders to join together, share ideas and advocate for resources that will advance family medicine in each of their schools and nationally. Second,the CFPC’s Division of Academic Medicine also provides support to undergraduate family medicine education through the work of the Undergraduate Education Committee (UGEC).  UGEC’s mandate is to  bolster and celebrate the work of a number of stakeholder groups: family medicine undergraduate leaders through CUFMED, family physicians who teach medical students and medical students.  

Current State of the Farm Team

CanMEDS-FMU, a set of undergraduate competencies from a family medicine perspective, was first developed in 2009 (8).  It set the stage to align family medicine undergraduate competencies with those of the broader undergraduate and postgraduate medical curricula.  CanMEDS-FMU was rewritten in 2019 to align with the revised CanMEDS goals (9). CanMeds-FMU 2019 seeks to establish family medicine as expert in the domain of generalism (9). LearnFM (formerly known as SHARC-FM), has provided a series of cases and learning tools for use in all family medicine undergraduate curricula nationally (10).  Curricular innovations such as mandatory longitudinal integrated clerkships grounded in family medicine have emerged as a key curricular component in many Canadian medical schools (11). Family medicine interest groups (FMIGs), coupled with the increased visibility of family medicine role models in the undergraduate curriculum and in undergraduate leadership have increased the footprint of family medicine in medical schools. And finally, approaches or experiences such as early, mandatory, longitudinal clinical experiences with family physicians, rural clerkships, and electives in both comprehensive care and focused practice have advanced family medicine as a key component of every undergraduate medical education program.

Additionally, UGEC continues to support several initiatives to raise further the profile of family medicine and family medicine as a career.  The recently released “Twelve Points to Consider When Talking to a Medical Student About a Career in Family Medicine” provides practical tips to discuss with medical students regarding the selection of family medicine as a career (12).  UGEC also provides important assistance to undergraduate family medicine program directors through an established peer review process; a peer consultant is offered to each undergraduate family medicine program in conjunction with the postgraduate accreditation visit.      

Moving Up from the Minors

The Canadian experience in boosting the profile of FM provides valuable  lessons learned for others seeking to promote family medicine.  Valuing undergraduate family medicine, creating a pathway through family medicine interest groups (FMIG), developing family medicine specific undergraduate teaching tools and creating opportunities for collaboration among undergraduate family medicine educators have been critical. None of this would have happened without the time, energy and effort of family medicine undergraduate teachers and the academic leaders who have guided the work over the past 25 years. A recent CFPC undergraduate family medicine retreat brought together thought leaders in family medicine and undergraduate education from across Canada to carve a path forward  to support the inclusion of the teaching of generalism in medical schools nationally(13).

Making the Show

Undergraduate family medicine has established itself as a key player in Canadian undergraduate medical education.  If you are a family medicine undergraduate teacher, please take a well-deserved “celly” ( celebration after scoring a goal) and if you know a family medicine teacher say “thank you coach” for a job well done. 

Acknowledgements

The authors wish to acknowledge all of our colleagues too numerous to name who have contributed to the successes of undergraduate family medicine.

Dr. Lisa Graves is Professor of Family and Community Medicine at Western Michigan University Homer Stryker M.D. School of Medicine in Kalamazoo Michigan U.S.A.

Dr. Maria Hubinette is a Clinical Professor in the Department of Family Practice in the Faculty of Medicine and Scholar at the Centre for Health Education Scholarship at the University of British Columbia in Vancouver, British Columbia Canada. 

Dr. Ivy Oandasan is Director of Education at the CFPC and Professor in the Department of Family and Community Medicine University of Toronto Toronto, Ontario Canada

Dr. Risa Freeman is Vice-Chair Education and Associate Professor in the Department of Family and Community Medicine University of Toronto Toronto, Ontario Canada

References

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