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Scholarship and Innovation are our Drivers of Quality Improvement in Primary Care

 
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DFCM is, above all, an educational institution comprising some of the best primary care providers in its region. It takes pride in scholarship for both its faculty and its students.

Every year, faculty members refine the postgraduate and undergraduate competency-based curricula. DFCM's programs are continuously updated to meet societal needs and respond to emerging trends. It has even developed specific education and scholarship opportunities.

Recently, DFCM has ensured the curricula emphasize the access and quality of care to vulnerable populations. It has made concerted efforts to expand quality improvement (QI) in care in its curricula and educational programs.

In the coming year, DFCM will build capacity in quality improvement through faculty and staff training to ensure there is a clear understanding of its core competencies and that these skills are well developed among faculty. 

 
 


I think it’s important for us to become mentors: I have had mentors throughout my career and now have mentees at the medical school and at University College.

—Dr. Marcus Law

 
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Palliative Care: Finding New Ways to Teach Softer Skills for Patient-Centred Care

Enhancing the palliative care learning experience can take many forms. Dr. Katie Marchington and Dr. Leah Steinberg are each actively engaged in improving the quality of learning for medical students and residents: Marchington through research and Steinberg through curriculum development. Their efforts are valuable, because as the Canadian population ages, an understanding of end-of-life care will become an increasingly important part of the physician’s practice.

Reflecting on Reflection

Marchington, a palliative care physician based at Toronto Western Hospital and the Kensington Hospice, conducted research into the effectiveness of a new palliative care reflective learning module for residents developed in partnership with co-principal investigator Dr. Jennifer Moore at Sunnybrook Health Sciences Centre. Marchington first incorporated it into her work with residents in 2015.

The module provides residents with readings about palliative care and asks them to email the instructors weekly with reflections about a clinical encounter. At the end of the module, residents are required to bring a reflection to share with the others.

Marchington surveyed the residents who participated in the module between March and August 2015 and conducted a focus group with module facilitators. She found that residents who completed the survey were pleased to have a forum to consider the difficult encounters they had with patients and families, though it was important to separate the reflection exercise from evaluation of the residents’ performance. The facilitators’ feedback, meanwhile, indicated that evaluating the reflections was meaningful but time-consuming.

“The idea of reflection in palliative care is very meaningful,” Marchington said. “We need to consider how to sustain a module like this from a manpower perspective.  It may require some modification. We also need to consider the best way for residents to develop this skill.”

End-of-Life Conversations

Steinberg, a palliative care physician at Mount Sinai Hospital, and three colleagues have developed and are beginning to study how best to implement an e-learning module that teaches residents and medical students on general and internal medicine rotations how to have goals of care conversations for to use with patients facing the end of life and their families.

“The module focuses on how to talk to patients and families about goals and values,” Steinberg said. “Sometimes, people in these situations are presented with out-of-context medical decisions and are asked to choose from a menu of treatments. A better approach is to discuss their goals for the future and then design the medical treatment to meet those goals.

“The e-learning module teaches communications skills and how to help patients with shared decision-making.”

The idea for the module grew out of a desire by Dr. Nasrin Safavi, a resident at Mount Sinai, to improve the way residents carry out the goals of care conversations. She discussed it with Steinberg and Dr. Christine Soong at Mount Sinai, and, conducted a needs assessment. Steinberg and Soong then designed the e-learning module with input from Safavi and a fellow resident, Dr. Andrea Daly. Steinberg says it’s the first e-learning module addressing this subject that she has seen, so it breaks new and important ground. It discusses the goals and components of the care conversation and the underlying skills required to conduct it.

“Physicians need to know when to have this conversation and why, and they also need to know how to do it,” Steinberg said. “The module embeds videos created to show the necessary skills, and has interactive components. It requires you to answer questions and reflect. You can then put the skills into practice, watch it again and reflect. You can go back to it again and again.”

The module, which is shorter than a workshop, but more in-depth than an article, was created for incorporation into the internal medicine curriculum at Mount Sinai. It will be given to every resident who does a rotation at Mount Sinai’s clinical teaching unit, but it applies to a much wider audience.

“This is meant to build a skill that everyone in health-care practice should have,” Steinberg said. “It’s listening to what our patients want in terms of their time left and being alert to those conversations. All health-care professionals should be able to pick up on cues that patients want to talk. The underlying skill is to listen without judgment.

“I can see it being used in an interdisciplinary way with only minor changes.”

Steinberg shared the module with others in March during the Division of Palliative Care’s grand rounds. She has tested it on learners and shown it to hospital colleagues and had an evaluation of the module planned for this past summer.

“This is all about making care patient-centred,” she said.

 


 

A New Model for Home-Based Primary Care

Home-Based Primary Care (HBPC) is a model that could help both at-home patients and their caregivers access a streamlined and integrated care model, according to a study led by researchers at University of Toronto Department of Family and Community Medicine (DFCM).

“HBPC, by definition, is intended to provide primary care for homebound patients,” says Dr. Thuy-Nga Pham, Assistant Professor at DFCM and physician at the South East Toronto Family Health Team. The delivery of care is effective and efficient because it is a full team of medical professionals tending to one patient. Team-based HBPC comprises an integrated team of health-care providers: Think nurse practitioner, physician assistant and a family doctor working hand-in-hand with the home-care case manager. The findings of our research demonstrate that team-based HBPC is a suitable, effective and efficient solution to reach populations that can’t make it out to the doctor’s office any longer.”

Six of the DFCM academic family health teams researched the impact of HBPC on families and other unpaid caregivers in their recently published qualitative study. Researchers interviewed a sample of people who serve as unpaid caregivers for relatives or friends needing care. Findings from this study reinforced the need for HBPC because the population is aging and the need for access to care is essential for homebound patients. Dr. Pham, a family doctor involved with a care team, notes that this model tends to benefit the patient but, more specifically, provides a bit of freedom to the caregiver.

“When I do home visits, I am always surprised to see a patient in his 90s and his spouse who is just as old as he or she is, administer insulin, make clinical decisions and even lift him or her up,” Pham says. “There is a real sense among caregivers that they are left alone. As a patient, you are lucky if you even have at least one person by your side, your family or friend as a caregiver. As soon as the HBPC team comes in, the patient, as well as the caregiver, feel that they have someone with whom they can troubleshoot and navigate the health-care system. It does not address all of the aspects of caregiver burden, but at least it helps them breathe a little easier.”

 
 Dr. Pham with a patient

Dr. Pham with a patient

 

Between 75 to 90 per cent of care offered by caregivers in Canada is unpaid. Family members or friends undertake the arduous task of providing nursing and clinical care to their loved ones. Some take on this work on a full-time basis. Most do not understand all the medical complexities associated with home care.  

The participants interviewed for the study described the long hours and gruelling work attached to caregiving. With HBPC, they welcomed the individualized and holistic care their loved one received, which included the co-ordination of their multiple appointments. Moreover, they appreciated the ability of just being able to call “a person.”

“It was so much worry before I go to them (sic)– what am I gonna do? Who am I gonna call?” says one participant in the study, who expressed frustration with the previous system. “I do not know what I was to do. There’s no number to call. Whom do you contact?"

Another participant answered,“It was not until the [HBPC team] came around that … it took that much pressure off me. It’s like, at least that’s one area I don’t have to worry about.”

While team-based, integrated HBPC is still a relatively new concept in Ontario, nine DFCM teaching units are actively offering this model of care. There is interest mounting in providing services at home for the elderly since Canada’s older population is expected to double in the coming years. DFCM’s Drs. Pham, Akhtar and Nowaczynski state that this study points to many opportunities to expand and enhance HBPC, including teaching DFCM family medicine residents relevant HBPC competencies. 

“HBPC needs to remain an essential element of primary care moving into the future,” says Pham. “Providing home-based primary care teaches competencies in family medicine in general. At the core, training our family physicians in this realm is crucial to ensure that we do not abandon or neglect our patients as they age or become frailer.”

This study was part of the BRIDGES program, a joint initiative led by the Departments of Medicine, the DFCM at the University of Toronto, and the Ministry of Health. Its goal was to explore the systemic health services delivery challenges in Ontario’s health-care system and support innovative models, testing and evaluating new solutions to improve care. 

 

Small changes can have huge returns: Residents learns lessons of deprescribing

A Residency Project Re-assesses Common Polypharmacy

Dr. Krista Margeson, a resident in her second year in Midland, Ontario, saw an 80 year old patient’s symptoms of delirium and weakness improve dramatically when his medications for diabetes, blood pressure and multiple other comorbidities were reassessed and reduced. Suddenly, the wider questions about polypharmacy— the use of multiple medications to manage coexisting health problems— became very real to her.

Currently, deprescribing medications happens sporadically. The check-box process that doctors currently use in re-prescribing is quick but often fails to reassess the whole patient's medication profile. Making changes takes more time and there is often little emphasis put on how to do this and what resources are available to assist. As Margeson reflects, “We’re always taught how to start drugs but I don’t remember being taught how to stop drugs.”

 Dr. Krista Margeson

Dr. Krista Margeson

She decided to focus her second year residency research project on the question of how to better manage patients' medication as a result of this experience. The patients under her preceptors’ care were primarily in long-term care, a frail and elderly population where instances of polypharmacy and its adverse effects were easy to identify. Margeson set out methodically to review the information on each patient under her preceptors’ care. She created a baseline by updating the cumulative patient profile (CPP) charts for each of them.

Next, she used an online tool, MedStopper, as a reference for each medication. It rates the impact of stopping each of a patient's medications from most to least important, based on balancing the likelihood of doing good versus causing harm. Krista made one medication recommendation per patient at every quarterly medication review, which her preceptor evaluated and implemented if in agreement. They found that most patients’ medications could be adjusted in some way.

This process of review, recommendation and adjustment was repeated every three months for each patient with the assistance of Krista’s preceptor. The risk of withdrawal was controlled by careful pacing.

“The trick is to do things slowly with the elderly,” says Margeson. “It’s about making small changes because you don’t know what will rock the boat. Most physicians think they are playing it safe by represcribing, and if there’s no plan for how to stop drugs and handle side effects, there's little incentive and the task can seem daunting.”

Margeson also found that communication with family members was essential. It was necessary to explain that stopping medications is about preventing harm, rather than denying treatment. This helped families make sense of these decisions.

Her project recommended generally increasing the number of times a patient's medication list is assessed by their family doctor to every three months where possible.

“Everyone is strapped for time, but it doesn't have to be a big production,” says Margeson. “It's something we don't think of often enough in our day-to-day clinical lives, but small, sustainable changes can produce a change in prescribing rates. And it's important because we know it will add up to a better quality of life for our patients.”

Margeson is now a locum family physician in Midland and Grimsby, Ontario, and says the project continues to impact her practice.

“I think that this project has made me more cautious when starting new medications, particularly with the older population,” she says. “It is much harder to stop medications than to not prescribe them in the first place.”

 

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Competency-Based residency Education sets a New curriculum standard  

Dr. Karl Iglar, former Director, Postgraduate Education in the Department of Family and Community Medicine, spoke with the DFCM’s communications staff about the program’s competency-based Family Medicine curriculum.

Q. What is competency-based medical education?

A. It is education delivered more actively that focuses on the attainment of outcomes rather than simply providing learning objectives that may or may not be achieved by a given trainee. It is the responsibility of both the trainee and the program to gather data to support progression and ultimate graduation from the program as a practice-ready Family Physician.  

In the Family Medicine curriculum developed at the University of Toronto, there are about 140 competencies across 11 clinical areas including Care of Children and Adolescents, Maternity Care and Emergency Medicine, to name a few. It is available on the University of Toronto portal both for residents and faculty. The curriculum is mapped to various assessment methods including the Evaluation Parameters on our Field Notes.

Q. When did it enter DFCM's curriculum?

A. We started developing the new curriculum in 2007 and implemented it for the first time in 2009. It has undergone several reviews since to ensure that it meets the needs of residents and is consistent with the goals of the College of Family Physicians of Canada.

It was created under the guidance of a steering committee, with various leads charged with writing the competencies for those domains in which they had expertise. The development of the curriculum was done in a rigorous and scholarly manner.

Q. How is it beneficial for students?

A. The curriculum is explicit. It details what the residents need to know and is reflected in the assessment methods used. 

Faculty can also teach to the standards. Since learners come into the program with a diversity of backgrounds, including variability in their undergraduate medical curricula, having clarity about prerequisites allows both learners and faculty to be aware of reasonable expectations for the beginning of a given learning experience.

Through assessment of their competence, the students get valuable feedback on how to improve to achieve the essential competencies of a practice-ready Family Physician. 

Q. How do you measure the effectiveness of students in the program?

A. We have various assessment tools for competency to make sure that by graduation, students have achieved the necessary competencies. The faculty submit Field Notes to assess student performance. Defining clear expectations allows for consistent and explicit assessment and the early identification of gaps and the need for remedial work.

Q. How has DFCM shown leadership through developing its competency-based curriculum?

A. We were one of the first family medicine programs in Canada to develop a competency-based curriculum and we presented our approach at national and international meetings. In addition, in order to disseminate what we had learned, we have published on the development of the curriculum and on progress testing.

Other programs, both nationally and internationally, have used our approach to competency curriculum development to develop their own programs.


Toronto International Program: Strengthening Family Medicine and Primary Care

 

Leaders from all over the world attend the Toronto International Program to learn how to strengthen family medicine and primary care. The goal of the program is to enhance leadership capacity in family medicine and primary care by building on lessons learned in the Canadian and global contexts.


Creating Physician Advocates: From Pilot Project to Undergraduate Curriculum Integration

Health advocacy is a core competency of the undergraduate medical curriculum. For preceptors, illustrating the realities of advocacy work within the health-care system can be challenging and requires tenacity.

 Paige Zhang

Paige Zhang

To give students real experience and increase physician advocacy, DFCM’s Undergraduate Program introduced a pilot project in 2015 at St. Michael’s Hospital that allowed students to choose an advocacy project as their Clerkship project. The projects encouraged students in a clinical setting to identify social determinants of health that influenced their patients’ health. Students learned to take steps to reduce or remove these social barriers, such as access to drugs or physiotherapy or adhering to medications, by identifying available resources and intervening on both individual and broader community levels.

The pilot was remarkably effective at developing empathy and resourcefulness among future doctors and empowering them to provide non-medical interventions for their patients. Advocacy projects are now an optional study block in the Undergraduate Clerkship Program.

Paige Zhang, recent MD graduate

The advocacy program ends with a presentation day, so I shared my work with my LInC student colleagues and preceptors and we had an interesting conversation about how much financial security affects our patients' health. This was complemented by a written reflection on my experiences.

What do you think are some of the key learnings and benefits you took away from doing an Advocacy Project?

Advocacy projects are a fantastic opportunity to start a dialogue with our patients about their experiences. I learned that being an advocate for patients can help them overcome barriers. I also learned to better understand a complex system. Something I thought was easy, such as accessing the financial benefits patients qualify for, is very complex; I didn’t realize this until I went through the process with my patient. This process also led to more questions about longer-term and community-based approaches to how we can advocate for patients with low incomes.

What does this experience mean for you going forward?

I started as a Psychiatry resident at St. Paul’s Hospital in Vancouver this July, where I hope to continue my training and work in advocating for patients. Through my experiences with the St. Michael’s Academic Family Health Team, I’m very interested in working with vulnerable populations and I think I’m more likely to reassess the things we tell patients to do and have greater empathy for their social limitations. The Advocacy Project with St. Michael’s Hospital was a unique and inspiring experience, and I hope to continue learning to be an advocate for my patients.

 

 

 

 

 

 

How did you discover the focus for an advocacy project?

I participated in the Longitudinal Integrated Clerkship Program (LInC) at St. Michael’s Hospital Sumac Creek family health site in Regent Park where there are many patients with complex social situations. I met a young mother who was struggling to balance her part-time work with caring for her four-month-old baby and completing high school. She came into the clinic to ask about baby formula options. During our conversation, she admitted that finances were a significant factor in her decision about which formula and other supports she could provide her child. She had concerns about making ends meet in taking care of herself and her daughter. 

How did you go about advocating for this patient?

After I had understood some of the challenges this young, student mother was tackling, I spoke with my preceptor, Dr. Cristina Pop. She suggested looking into financial incentives that might apply to her situation and provided me with some resources. I began researching Ontario Disability Support Program (OW/ODSP) and found that, even with my literacy and research skills from many years of education, it was very challenging to understand the process. I couldn’t Imagine what it was like for my patient to navigate the financial options available to her.

The patient and I met again and I referred her to an income health promoter who could help her access services and obtain benefits that she qualified for. Once she was working with the caseworker, we had to wait for approvals on her applications and that was challenging, too, because it required her to manage herself financially until she had the money.

Based on this experience, I wanted to develop a couple of longer-term activities. Under the supervision of my psychiatry preceptor and poverty advocate, Dr. Michaela Beder, I developed a workshop on how patients can access financial supports based on a previous presentation by Dr. Beder and Dr. Andrew Pinto. I’ve been able to facilitate this workshop twice for patients transitioning out of homelessness at the STAR Learning Centre at St. Michael’s Hospital. There were always interesting shared experiences and engaging discussion from the participants!


Dr. Marcus Law Brings a Family Medicine Perspective to Educating Med Students

 

How did you get involved at the medical school?

It really started with my work as the DFCM residency recruitment co-ordinator and postgraduate site director for Michael Garron Hospital (formerly Toronto East General Hospital). I then took on a role in leading education technology at DFCM – I’ve always had an interest in modernizing education. This led to moving to the Faculty of Medicine as the Lead in eLearning in 2011, and then to the MD Program in 2013 with the goal of transforming the preclerkship curriculum [now Foundations].

How did your background as a family physician prepare you for your current role?

I really saw the opportunity for me to contribute to medical education based on my background and role as a generalist. Being a generalist provides me with a unique perspective and aligns well with my interest and passion for innovating for better learning and teaching.

The Foundations curriculum has a focus on generalism because it is designed to prepare students for future learning – they don’t need to know everything in the first two years but they need to have a good understanding of the basic science, clinical concepts and psychosocial issues related to health conditions. I saw a huge potential to better integrate these concepts right from the start of medical school. Students also need to learn how to talk to, treat and understand managing patients holistically, in addition to learning how to collaborate with members of an interprofessional team.

Why do you think it’s important for faculty to get involved at the University? How do you propose they start?

I think it’s important for us to become mentors: I have had mentors throughout my career and now have mentees at the medical school and at University College.

I also tell people to find and define your passion and figure out what matters to you – once you find it, then the opportunities open up. One way to do this is to continue to learn by taking courses. I took one at Harvard and Rotman and I completed an MBA at Arizona State University. Even now, I continue to further my learning and education in my interests. It also helps for networking and really exploring if I want to continue to do this and where I will go in the future.

Where do you think you will go next?

I really don’t know. I deliberately don’t plan out my career that rigidly – having a complete map of my career might actually narrow my view of what I can achieve if I fixate on a particular path. I just continue to explore new learning and ideas and expand my network. I’m finding out what I’m good at and what brings joy to my work. Creativity makes me happy – I always look for opportunities that involve creativity and advocacy. And, I don’t need to be fixated on specific goal – opportunities will continue to unfold if I keep my mind open. My only goal is to continue to make an impact and contribute to my communities.