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Standards for the Accreditation of Family Medicine Residency Programs

A:  Curriculum

Introduction

The curriculum should be guided by the following educational principles:

1. Family physicians must play the principal role in educating family medicine residents. Their teaching should be supplemented by that of family medicine-oriented specialists. There must be opportunities for residents and educators in various health care disciplines to work together in providing care.
2. Programs must demonstrate that effective experiential learning of continuity of patient care occurs within the program. Residents must have a group of patients for whom they assume significant responsibility over an extended period of time and in different patient care settings. Residents must learn the skills of coordinating the interprofessional care of patients with multisystem illness, including the maintenance and use of high-quality health care records and other forms of communication. Residents must develop an appropriate attitude toward the establishment of enduring relationships with and ongoing commitments to their patients. Development of such an attitude should be incorporated into block time. It is also recommended that residents on rotations other than family medicine should be released for a half-day each week so they can follow their own identified group of family practice patients.
3. The curriculum should be flexible to allow residents to develop the special skills they will need to practice in widely varied settings.

Programs should organize block rotations in other clinical disciplines when the concentration of time and experience would be relatively advantageous. Such experience could include disciplines such as internal medicine, surgical specialties, obstetrics, geriatrics, psychiatry, pediatrics, and emergency medicine. Within these block rotations, residents should have time protected for horizontal experiences relevant to the block, as well as the half-day release to their family practice offices. These experiences might include work in ambulatory clinics or day hospitals, community services or seminars, and scholarly work. The department of family medicine will plan and approve these experiences in consultation with the specialty departments involved. Programs should provide opportunities for residents to select other experiences that meet their individual learning needs.

Curriculum Content

Curriculum Guidelines related to the Family Physician is an Effective clinician.

The experiences arising from time spent in family practice settings are vital to the development of effectiveness as a family physician. Family practice time must provide residents with the opportunity to experience both the role of the family physician and the scope of family practice. The program must ensure that residents maintain meaningful contact with their professional discipline throughout the program.

Block time in family practice must occur in both years. A minimum of eight months of a two-year program must be spent based in a family medicine teaching practice, and at least one block should consist of four continuous months in the same teaching practice. The first year must include at least two months of family practice block time. These two months should be consecutive. During block time in family practice, residents must assume major responsibility for integrating full care for those patients with whom they have continuing relationships. Block time should be organized to reflect appropriate patterns of practice, and residents must work together with effective family physician role models.

All family medicine residents must spend a minimum of 8 weeks in a rural family practice as part of their core family medicine experience.

The College of Family Physicians discourages family medicine block rotations of less than 2 months (8 consecutive weeks) as short exposures to a particular practice do not normally allow a resident to develop any meaningful levels of continuity, or responsibility. Exceptions to this would be an introductory month to a practice in which the resident will remain attached for continuity of care and where the resident will be returning for a longer experience later in their program.

Just as practicing family physicians work largely in office settings, so residents must be based primarily in an office setting. Practice-based patient care activities must comprise a minimum of six half-days each week. In addition to actual office-based patient contacts, such time can include weekend clinics or rounds, hospital visits to patients admitted through the practice, and other practice-based patient care activities. Residents must maintain continuing responsibility for their patients in various settings—such as hospital, home, and long-term care institutions. Residents must be involved in providing after hours care as part of their patient care responsibilities during their core family practice experiences.  After hours care must be limited to patients for which the family practice service would normally be responsible.

To promote active reflection and deeper understanding of important concepts, block time must also have an academic component. Each week, time should be allocated to a variety of activities, including seminars and didactic teaching, horizontal electives, free study time, and protected time for work on practice audits and research projects. Time should be provided for horizontal electives, and these experiences may comprise up to three half-days a week. Their selection should be guided by relevance to patient care in family practice. For example, dermatology, emergency care, surgical procedures, adolescent medicine, and behavioral medicine are relevant electives.

The practice-based experience should have a reasonable balance of acute and chronic care, ambulatory and hospital care. It should also provide a breadth of involvement with patients who are from all age groups and have a variety of problems, including obstetrical patients. There must be a progression of responsibilities and activities as a resident moves through the program, ultimately approaching the level of function expected of a family physician in practice.

Life Cycle
The family practice settings in which residents obtain their training should include a wide range of age groups and clinical problems, including care of dying patients. Residents should not be limited to a practice that is too heavily skewed toward any particular age group or special interest area. Should residents be assigned to such a practice, the program must make provision to ensure that such residents are able to meet any deficiencies in learning opportunities.

Care of Children and Adolescents
The family medicine settings in which residents are based for eight months of their training must have an adequate volume of office visits by children and adolescents to allow residents to study children’s normal growth and development and to learn the diagnosis and management of common pediatric and adolescent problems that present in the family practice setting.

Other clinically based experiences caring for children should be added as a supplement, and should allow a concentrated experience in common childhood health problems that may require secondary level care. Ideally this training should be ambulatory and involve care of pediatric emergencies as well as some experience in outpatient clinics. Because adolescents attend physicians’ offices infrequently, clinical experiences should extend beyond the office to outpatient clinics, school-based clinics, reproductive health clinics, and street clinics. Any time spent on a hospital pediatric ward should expose residents to a wide range of pediatric and adolescent problems, and include hospital management of those illnesses that commonly present to family physicians. Training in neonatal resuscitation must be provided.

Care of Adults
Specialty rotations in internal medicine should be arranged to supplement the family practice experience, and should include both ward-based and ambulatory-based experiences. Experience should include the assessment and care of the acutely ill. Family medicine residents should receive training only on wards in which they will see a wide variety of internal medicine problems appropriate to family practice. Hospital-based block rotations on family practice wards are valuable experiences, but these will be considered part of the hospital-based experience and not part of the eight-month block experience in office-based family practice.

To provide effective care, residents must become knowledgeable about the special health care requirements specific to men and women. The family practices in which residents are trained should have an adequate patient base to allow experience of these health areas.

Although family physician teachers may not include obstetrics in their practice, residents in training programs must have the opportunity to follow some (preferably six or more) obstetrical patients to term and through labor and delivery throughout the course of the two-year program. In addition, residents must have an adequate specialty experience in obstetrics, which focuses on labor and delivery. It is important that this learning occur in a setting in which family physicians are also working. Residents must also gain experience in gynecological problems related to family practice in outpatient settings.

Residents must be well acquainted with important physical and psychosocial aspects of men’s and women’s health care, including occupational health, family planning, spousal abuse, sexual assault, and sexual abuse. Residents must become familiar with gender-based differences in the management of common health problems in men and women. This area of training can be enhanced by a wide range of horizontal experiences in occupational health clinics, family planning clinics, rape crisis centers, women’s shelters, and women’s health clinics, and by other related experiences.

Care of the Elderly
Residents must learn the special skills, knowledge, and attitudes related to care of the elderly. Residents must be able to do a comprehensive functional and clinical assessment of the frail elderly, including assessment of mental function. They must also be familiar with the atypical presentation of illness and with the management of common geriatric and psychogeriatric problems, both physical and psychological, in hospital, institutional, and community settings. Residents should learn to be effective team members by participating in a multidisciplinary geriatric team. A variety of resources, including family medicine and specialty faculty with expertise and training in care of the elderly, should be available to residents. It is expected that family practice block time will include an opportunity for residents to care for ambulatory elderly patients in the home and the office. In order to meet these objectives, programs should make use of ambulatory clinics, long-term care programs, and hospital rotations, as well as family practice settings.

Palliative and End of Life Care
Residents must learn the skills, knowledge, and attitudes related to the management of physical, psychological, social and spiritual needs of dying patients and their families. Residents must be familiar with medical and societal attitudes towards death and dying.

Other clinical skills

Surgical and Procedural Skills
Residents in family practice settings must have an opportunity to learn surgical and procedural skills that can be practiced appropriately in the family practice office, or in outpatient or emergency department settings. These skills should be taught by family physicians if possible, but learned in specialty horizontal experiences if necessary. Surgical and procedural skills can be learned in a variety of different settings and programs should make use of block or horizontal experiences in such areas as surgery, emergency medicine, dermatology, and treatment of musculoskeletal problems.

Residents should also have the opportunity to learn other skills of particular interest or relevance to their career plans. They should be encouraged to learn the general principles of surgical procedures so that they can add to their skills once they have graduated from the training program. There should be an opportunity in either a surgical rotation or other setting to learn the principles of pre- and postoperative care, and to develop the ability to recognize patients requiring acute surgical intervention.

Behavioral Medicine
Residents in family medicine must have an opportunity to learn behavioral medicine relevant to family medicine. Behavioral medicine may be taught in a variety of settings and formats. These should include a strong orientation to interviewing skills and the doctor-patient relationship within the context of the family practice office setting. These experiences should be supplemented by seminars, as well as by other horizontal and block rotations that may be deemed appropriate. Programs should work closely with the department of psychiatry to develop appropriate rotations and experiences for residents in crisis management, short-term psychotherapy, and family counselling. Programs may wish to integrate other appropriate health care workers in a complementary role in the teaching of residents, however, family physicians must provide and coordinate core teaching.

Emergency Care
Residents in family medicine must have an opportunity to learn and experience the delivery of care in acute care settings, including the emergency department. Acute care settings provide the resident with an opportunity to learn the skills of triage and surgical assessment, a variety of procedural skills related to trauma management, managing medical emergencies, and working with a team. The setting selected for this training should provide experience with a wide variety of patient problems in children, adolescents, adults, and the elderly. These sites should also provide an opportunity for residents to work with family physicians who include emergency medicine as part of their professional activity. Supervision of the residents should be done by both emergency physicians and family physicians.

Curriculum Guidelines related to Family Medicine is Community based.

Residents must learn and experience the role of the family physician in settings other than the office. For hospital care this can be best achieved through the residents admitting their own patients from their family practice setting and permitting residents’ to follow them, when appropriate, in hospital. In this context residents must learn the skills of referral and consultation. Such skills can be enriched through the use of inhospital family practice rotations, and through resident interaction with specialty trainees in the hospital. Residents should also learn about the cost-effective use of resources and the physician’s role in hospital committees through participation and formal teaching. Residents must have a minimum of 2 months experience maintaining clinical responsibility for their family medicine patients in hospital settings in which their family physician preceptors are the primary providers of inpatient care.

Residents must learn the principles of home care for patients with chronic illness, dying patients, and elderly patients.

Residents in family medicine must learn how to identify and respond effectively to the needs of communities. This can be accomplished through introducing residents to the role of the family physician in urban, rural and remote areas.

Residents must have knowledge of and be willing to draw upon the community’s resources, such as medical consultants, other health professionals, and community agencies.

Residents must become familiar with the medicolegal and medical/ethical issues relevant to family practice and should become knowledgeable about licensure requirements and their responsibilities as professionals.

The residency training program will provide a curriculum in family medicine ethics with the following minimum characteristics:

1. The teaching of a knowledge base of the relevant bioethics and medicolegal literature pertaining to ethical issues inherent in family practice.
2. The teaching of analytical skills in a systematic and comprehensive manner suitable to the identification and resolution of ethical issues inherent in family practice.
3. The perspective of the teaching program should be one of clinical relevance and should therefore focus on ethical issues confronted daily in family practice (such a program presupposes a more theoretical undergraduate exposure to ethics in medicine). To this end, it should be:
   
   - integrated as much as possible into existing clinical training of family phyisicians
   - developed in parallel with a faculty development program, so that teachers of family medicine can effectively accomplish this integration
   - provided in a multi-disciplinary context
4. There must be a formal evaluation of the attitudes, knowledge and skills pertinent to the ethics of family medicine.

Curriculum Guidelines related to the Family Physician is a Resource.

The family physician must be able to function as a resource to his/her practice population.

To fulfill their role, physicians must be able to evaluate new knowledge critically and interpret its relevance to the practice and the community. Residents must be taught the basic principles of critical appraisal and apply these in daily practice and in the preparation of seminars and presentations.

Each residency program must demonstrate a commitment to integrating the tools of information management into patient care, teaching and research.

This will require that the program have an organized approach to promoting the use of, and fostering the teaching of informatics. Essential elements of this commitment will include:

1. Providing residents and faculty with ready access to the tools of information management in the areas where they usually conduct patient care.
2. Developing, implementing and evaluating a resident curriculum and faculty development program in family medicine informatics.

Family physicians must be able to assess their own skills, knowledge, and practices through practice audit and other quality assurance activities. Residents must learn the basic principles of quality assurance, including setting standards, measuring performance against those standards, and follow-up to ensure they were met; residents must participate in practice audit activities during residency training.

Family physicians should be able to manage efficiently the business aspects of practice, including scheduling, office supplies and equipment, personnel, on-call systems, medical records, etc. Residents must be taught the basic principles of, and have the opportunity to participate in, practice management decisions, particularly in community practice rotations. Residents must learn the skills related to managing information, such as health care records and other forms of patient information.

Family physicians have a responsibility to provide preventive medical care to their patients of all ages. Residents must learn the principles of preventive care and be able to implement appropriate screening and patient education activities in their teaching practices.

Curriculum Guidelines related to the Doctor-Patient Relationship.

The special nature of the doctor-patient relationship in family medicine will be learned primarily during the time in family practice, although an effort must be made to integrate this essential principle into the entire program. Guided reflection on clinical experience is essential to learning in this area. This type of learning requires particular kinds of patient care experiences, including responsibility for providing continuing care for a group of patients over a period of many months; faculty support and guidance to prevent difficult experiences from being negative or overwhelming; and opportunities for discussing patient-physician relationship issues with experienced, skilled, and sensitive teachers of family medicine.

Time for reflection and reading about the doctor-patient relationship is important, and residents must be encouraged to expand their self-awareness in the context of providing patient care.

Among the knowledge, skills, and attitudes that must be included are the following:

B: Program Organization

A residency training program in family medicine must be based in a university department of family medicine, from which the total training of all residents registered in that program can be developed and coordinated in collaboration with other relevant disciplines within the medical school.

Each department must have an individual identified as the director of postgraduate education, who is responsible for overseeing all of the postgraduate educational activities of the family medicine residency program. The postgraduate director must have adequate time and support to supervise and administer the postgraduate education program. The residency postgraduate director is responsible to the head of the department of family medicine and to the postgraduate dean of the faculty of medicine.

The family medicine postgraduate director must hold certification in family medicine (CCFP).

The postgraduate director of the department of family medicine will be assisted by a postgraduate education committee, which will include representation from full- and part-time faculty, residents, allied health professionals with appointments within the department, and teaching units. The resident representatives on the postgraduate education committee must be selected by their peers and oriented to their role and responsibilities, both as members of the committee and as resident representatives. This committee should meet at least four times a year.

The family medicine postgraduate education committee of the department must have the responsibility to develop a clear curriculum plan. Such a plan must include objectives relating to knowledge, skills, and attitudes, and be based upon the educational objectives and the four principles of family medicine defined by the CFPC. 

The postgraduate education committee should be responsible for selecting candidates for admission to the program. The selection will be in accordance with policies determined by the university department of family medicine.

All health care facilities offering resident training experiences (other than elective experiences) must have an affiliation agreement or a letter of understanding with the relevant faculty of medicine, and should be encouraged to receive accreditation by the Canadian Council on Health Services Accreditation (CCHSA). 

C: Resources

Clinical Teaching Resources

The department of family medicine must have sufficient financial resources, administrative structure, and accountability to ensure that its educational program is effectively administered throughout all the training sites affiliated with that department.

Each residency training program must provide appropriate family practice teaching settings for the training of residents. Such practices may be family practice teaching units staffed by geographic full-time family physician teachers appointed within the department of family medicine, or community practices staffed by family physician teachers with part-time appointments within the department of family medicine. All or part of the residents’ family practice experience may occur in either kind of setting.

Such practices must provide an adequate patient volume and variety to allow residents an opportunity to experience all aspects of family practice, including obstetrical care.

Teaching practices must allow a resident to acquire the identity of a family physician. The resident’s time in family practice must be in a setting that allows the resident to undertake all the tasks and responsibilities outlined in the introduction to this section. There should be an opportunity for continuity of care to allow residents to observe the natural history of disease, and a requirement that residents be available to and responsible for a group of patients over time.

The practice must be organized in such a manner that residents can build a defined panel of patients during their time in their primary teaching center. Resident responsibility should be such that patients recognize the resident as one of their personal physicians, and that residents are directly responsible for the delivery of care to those patients with whom they are identified.

Such practices should demonstrate effective practice management and quality assurance programs.

The teaching sites must have in place the appropriate equipment and technology to teach residents effectively and to assess their skills as family physicians. Such equipment may include one-way mirrors and video or audio equipment. 

Faculty Resources

Family medicine should be taught by family physicians whose philosophy and practice are consistent with the aims and aspirations of family medicine, as defined by the four principles.

1. All full-time family physician teachers must hold certification in family medicine (CCFP) and hold academic appointments in the university Department of Family Medicine. This does not preclude the appointment of family physicians with other or equivalent qualifications. However, any full-time family physician teacher, appointed to a university Department of Family Medicine, who does not hold certification in family medicine with the College of Family Physicians of Canada should seek certification within four years of appointment.
2. All part-time family physician teachers must hold qualifications acceptable to the College of Family Physicians of Canada, which would normally be certification in family medicine (CCFP). All such teachers, who do not hold certification in family medicine, should be encouraged to obtain certification with the College of Family Physicians of Canada (CCFP) within four years of appointment.
3. In a community practice, staffed by part-time family physician teachers, at least one of these teachers must be a certificant in family medicine. One of the certificants must be responsible for the co-ordination of resident education in the practice.
4. All family physician teachers required to hold certification in family medicine must maintain their certification.
5. The ratio of supervisors to residents during any family practice clinical experience should be no less than 1 supervisor to 4 residents. The cohort of supervisors must consist of family physician teachers whose practices are based in the teaching unit and who can function as role-models for the residents.
6. Specialty and other health professional teachers should have university appointments in keeping with their academic responsibilities. These teachers may have appointments in departments of family medicine when appropriate. Specialty areas should be taught by family physicians with special skills and by family practice oriented specialists (including other health-care professionals). Specialist teachers should be those who are familiar with the problem solving skills and orientation of family practice, and who are directly involved with family physicians in daily practice.

 Source: College of Family Physicians of Canada Standards for Accreditation of Residency Training Programmes

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