A 'minimal core curriculum' for Family Medicine in undergraduate medical education: a European Delphi survey among EURACT representatives

Development of a list of core clinical topics suitable for a shared primary care curriculum for medical undergraduates in Malaysia: A Delphi study

In the last few decades, primary care medicine (PCM) is increasingly recognised as a cornerstone of an efficient and effective healthcare system. However, the PCM discipline is now facing challenges such as a shortage of doctors. One of the possible reasons could be the lack of comprehensive PCM curricular components in the undergraduate medical programmes. This study aimed to develop a list of core clinical topics suitable to be used as a shared PCM curriculum for undergraduate education in Malaysia. A Delphi survey that consisted of three iterative rounds with feedback was used in this research. The participants included PCM experts involved in the undergraduate level of PCM teaching. These experts were selected based on the criteria developed by two senior academicians in PCM medical education. The final developed list contained 34 core clinical topics that should be incorporated into the undergraduate PCM curriculum. The findings will be useful in establishing the policies and guidelines of PCM education for undergraduates in various medical schools. This study may also promote the field of PCM and encourage more doctors to take up the speciality. Lastly, it provides essential information to address the knowledge gap in PCM education among undergraduate medical students in Malaysia.

Defining Essential Topics and Procedures for Korean Family Medicine Residency Training

BACKGROUND

This study aims to create a comprehensive list of essential topics and procedural skills for family medicine residency training in Korea.

METHODS

Three e-mailed surveys were conducted. The first and second surveys were sent to all board-certified family physicians in the Korean Academy of Family Medicine (KAFM) database via e-mail. Participants were asked to rate each of the topics (117 in survey 1, 36 in survey 2) and procedures (65 in survey 1, 19 in survey 2) based on how necessary it was to teach it and personal experience of utilizing it in clinical practice. Agreement rates of the responses were calculated and then sent to the 32 KAFM board members in survey 3. Opinions on potential cut-off points to divide the items into three categories and the minimum achievement requirements needed to graduate for each category were solicited.

RESULTS

Of 6,588 physicians, 256 responded to the first survey (3.89% response rate), 209 out of 6,669 to the second survey (3.13%), and 100% responded to the third survey. The final list included 153 topics and 81 procedures, which were organized into three categories: mandatory, recommended, and optional (112/38/3, 27/33/21). For each category of topics and procedures, the minimum requirement for 3-year residency training was set at 90%/60%/30% and 80%/60%/30%, respectively.

CONCLUSION

This national survey was the first investigation to define essential topics and procedures for residency training in Korean family medicine. The lists obtained represent the opinions of Korean family physicians and are expected to aid in the improvement of family medicine training programs in the new competency-based curriculum.

Motivations for and Challenges in the Development of Global Medical Curricula: A Scoping Review

PURPOSE

The aim of this scoping review is to understand the motivations for the creation of global medical curricula, summarize methods that have been used to create these curricula, and understand the perceived premises for the creation of these curricula.

METHOD

In 2018, the authors used a comprehensive search strategy to identify papers on existing efforts to create global medical curricula published from 1998 to March 29, 2018, in the following databases: MEDLINE; MEDLINE Epub Ahead of Print, In-Process, and Other Non-Indexed Citations; Embase; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; PsycINFO; CINAHL; ERIC; Scopus; African Index Medicus; and LILACS. There were no language restrictions. Two independent researchers applied the inclusion and exclusion criteria. Demographic data were abstracted from publications and summarized. The stated purposes, methods used for the development, stated motivations, and reported challenges of curricula were coded.

RESULTS

Of the 18,684 publications initially identified, 137 met inclusion criteria. The most common stated purposes for creating curricula were to define speciality-specific standards (50, 30%), to harmonize training standards (38, 23%), and to improve the quality or safety of training (31, 19%). The most common challenges were intercountry variation (including differences in health care systems, the operationalization of medical training, and sociocultural differences; 27, 20%), curricular implementation (20, 15%), and the need for a multistakeholder approach (6, 4%). Most curricula were developed by a social group (e.g., committee; 30, 45%) or Delphi or modified Delphi process (22, 33%).

CONCLUSIONS

The challenges of intercountry variation, the need for a multistakeholder approach, and curricular implementation need to be considered if concerns about curricular relevance are to be addressed. These challenges undoubtedly impact the uptake of global medical curricula and can only be addressed by explicit efforts to make curricula applicable to the realities of diverse health care settings.

The Development of a Competency Assessment Standard for General Practitioners in China

This paper describes the development of a competency assessment standard for General Practitioners in Shenzhen, China. The standard is to be used for developing and delivering the training curriculum for General Practitioners and to enable rigorous assessment of the mastery of the standards by GP trainees. The requirement for the training of General Practitioners in China is mandated by government policy requires an international standard curriculum to meet the needs of patients and the community. A modified Delphi process was employed to arrive at a curriculum consensus. An expert panel and 14 expert working groups derived from the expert panel were established to review and evaluate national and international competency standards for General Practice and develop a set of standards, through a modified Delphi methodology. Forty three experts were involved in the project. The project resulted in a detailed curriculum statement. The curriculum was then used in 2017 and 2018 where pilot examinations of GP trainees (n = 298 and n = 315, respectively) were conducted to assess the trainee's competencies against the Standards. The examination included two modules, a written test (Module A) and a practical test (Module B). The success rate for participants was relatively low with the majority not successfully completing the assessments. The assessments will be further refined in subsequent work. The project achieved its goal of developing a rigorously evaluated standard to support clinical practice and the training and assessment of GPs.

Can a family medicine rotation improve medical students' knowledge, skills and attitude towards primary care in Vietnam? A pre-test-post-test comparison and qualitative survey

OBJECTIVES

Well-designed studies on the impact of a family medicine rotation on medical students are rare, and very few studies include a qualitative component. This study aimed to determine the improvement of medical students' knowledge, communication skills and attitude towards primary care and explore their perceptions after rotations, in comparison with a control group.

METHODS

We used a mixed-methods design, comprising a pre-test-post-test comparison between a sample of trained students who took family medicine rotations and a control group and a qualitative survey. The measurement of improvement included (i) multiple choice question testing, (ii) objective structured checklist examinations, (iii) self-reporting and (iv) interviews and focus group discussions. Data were collected from August 2017 to June 2018.

RESULTS

There were 696 students in the trained group and 617 controls. The two groups' baseline scores in knowledge, communication skills and attitude were not significantly different. Knowledge covering five domains of family medicine (Pearson's r from 0.6 to 0.9) improved significantly, as did attitudes towards primary care in the trained group. There were no differences in communication and counselling skills between the two groups for four situations, but for two-health check-ups and mental health care-skills were significantly improved (Pearson's r from 0.28 to 0.43). The qualitative survey showed highly positive feedback from trained students.

CONCLUSIONS

The family medicine rotation significantly improved students' knowledge and attitude towards primary care and some communication skills. Further studies should investigate students' interest in and career choice for this discipline.

Partial adoption of 'minimal core curriculum' in undergraduate teaching of family medicine: A cross-sectional study among Central and South-Eastern European medical schools

Background: In 2011, Tandeter et al. published a list of 15 themes, based on a Delphi survey among representatives of the European Academy of Teachers in General Practice and Family Medicine (EURACT), and suggested this be the ‘minimal core curriculum’ (MCC) for undergraduate education in family medicine.

Objectives: To determine: (1) if medical schools in the former Yugoslavia region are familiar with the MCC; and (2) to what degree it is being taught to medical students.

Methods: In July 2015, a questionnaire was distributed to 19 medical schools in the former Yugoslavia region. A copy of the description of the curriculum for GP/FM was requested from participants. Two researchers conducted content analysis of the curricula according to the 15 predefined MCC themes, independently.

Results: Thirteen (68%) medical schools responded. Of these, 10 (77%) stated that they were familiar with the MCC. Not a single institution encompassed all 15 MCC themes. The number of themes included by individual medical schools ranged from 6/15 (40%) to 13/15 (87%).The following themes were covered by 12 of 13 (92%) medical schools: Introduction to GP/FM; communication skills; prevention and health promotion; and management of chronic diseases. The three themes most poorly covered were: consulting skills (5/13), management of diseases at an early, undifferentiated stage (2/13) and decision-making based on prevalence and incidence (1/13).

Conclusion: Despite familiarity with EURACT’s MCC among medical schools in the former Yugoslavia region, significant variation in curricula content exists, and no curriculum covered all MCC themes.

Core principles of evolutionary medicine: A Delphi study

BACKGROUND AND OBJECTIVES

Evolutionary medicine is a rapidly growing field that uses the principles of evolutionary biology to better understand, prevent and treat disease, and that uses studies of disease to advance basic knowledge in evolutionary biology. Over-arching principles of evolutionary medicine have been described in publications, but our study is the first to systematically elicit core principles from a diverse panel of experts in evolutionary medicine. These principles should be useful to advance recent recommendations made by The Association of American Medical Colleges and the Howard Hughes Medical Institute to make evolutionary thinking a core competency for pre-medical education.

METHODOLOGY

The Delphi method was used to elicit and validate a list of core principles for evolutionary medicine. The study included four surveys administered in sequence to 56 expert panelists. The initial open-ended survey created a list of possible core principles; the three subsequent surveys winnowed the list and assessed the accuracy and importance of each principle.

RESULTS

Fourteen core principles elicited at least 80% of the panelists to agree or strongly agree that they were important core principles for evolutionary medicine. These principles over-lapped with concepts discussed in other articles discussing key concepts in evolutionary medicine.

CONCLUSIONS AND IMPLICATIONS

This set of core principles will be helpful for researchers and instructors in evolutionary medicine. We recommend that evolutionary medicine instructors use the list of core principles to construct learning goals. Evolutionary medicine is a young field, so this list of core principles will likely change as the field develops further.

How do national specialty groups develop undergraduate guidelines for medical schools, and which are successful? A systematic review

PURPOSE

To better understand the steps undertaken by medical specialties to develop and implement undergraduate national, and international, educational guidelines for use in medical schools, and to find what makes them successful in terms of uptake and knowledge.

METHODS

Systematic review of databases to find inter- and nationally-created undergraduate medical specialty guidelines, and descriptions of development and analysis, from 1998 to January 2015.

RESULTS

Ninety six eligible papers were found, covering 59 different guidelines in 32 specialties. Five documented from development to revision. Development often required multiple stages and methods, 10 using the Delphi technique. Twenty two guidelines mapped to recommended government standards. Twenty papers analyzed curricula. No guideline was used in every relevant medical school.

CONCLUSIONS

This is a comprehensive review of the processes involved in creating international and national guidelines, with emphasis of key points for those considering similar undertakings. These include thorough needs analysis of multiple groups involved in the delivery of the curriculum; and engagement of relevant parties throughout development, to ensure relevance and increase buy-in. Flexibility is important, to allow use in medical schools with different methods of teaching. Ongoing evaluation and update are also critical steps that must not be forgotten.

Strengthening general practice/family medicine in Europe-advice from professionals from 30 European countries

Background

Substantial variations are still to be found in the strength of general practice/family medicine (GP/FM) across Europe regarding governance, workforce competence and performance, as well as academic development and position. Governments are encouraged by the WHO to secure high quality primary health care to their population, a necessity for reaching the goal “Health for all”. The present study aimed at investigating the opinions of council members of the European Academy of Teachers in General Practice (EURACT) on necessary actions to strengthen the position of GP/FM in their country.

Methods

The study used a mixed methods exploratory sequential design. EURACT representatives from 32 European countries first participated in brain-storming on how to strengthen GP/FM in Europe. Later, representatives from 37 countries were asked to individually score the relevance of the proposed actions for their country on a 9-point Likert scale. They were also asked to evaluate the status of GP/FM in their country on four dimensions.

Results

Respondents from 30 European countries returned complete questionnaires. To build and secure GP/FM as an academic discipline comprising teaching and research was seen as essential, regardless the present status of GP/FM in the respective country. To build GP/FM as a specialty on the same level as other specialties was seen as important in countries where GP/FM held a strong or medium strong position. The importance of common learning objectives and a defined bibliography were stated by respondents from countries where GP/FM presently has a weak position.

Conclusions

In order to strengthen GP/FM throughout Europe, EURACT and other professional organizations must establish common goals and share expertise between countries. To influence decision makers through information on cost-effectiveness of a GP/FM-based health care system is also important.

Rumo à educação baseada em competências: construindo a matriz do internato em Medicina de Família e Comunidade

Objetivo: Elaborar a matriz de competências a serem desenvolvidas pelos estudantes durante os três meses de estágio no internato em Medicina de Família e Comunidade na Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA). Métodos: Foi realizada revisão de literatura sobre o referencial teórico do ensino baseado em competências sobre escolas médicas que utilizassem o ensino baseado em competências na especialidade e sobre as principais diretrizes nacionais e internacionais sobre o tema. Diante da revisão de literatura, foi discutida a aplicabilidade das recomendações no contexto do internato da UFCSPA. Resultados: Dezoito competências foram elaboradas e divididas em quatro eixos: Geral; Abordagem Individual; Abordagem Familiar e Abordagem Comunitária. Cada competência foi detalhada em um ou mais componentes. Para cada componente, foram identificados os métodos de ensino e de avaliação atualmente utilizados no programa do internato. Conclusão: Com a definição da matriz, as competências, antes desenvolvidas de forma intuitiva, foram organizadas de modo a viabilizar a revisão e adequação dos processos de ensino e avaliação.

Standing on the Precipice: Evaluating Final-Year Physiotherapy Students' Perspectives of Their Curriculum as Preparation for Primary Health Care Practice

Purpose: To explore final-year physiotherapy students' perceptions of primary health care practice to determine (1) aspects of their curriculum that support their learning, (2) deficiencies in their curriculum, and (3) areas that they believe should be changed to adequately equip them to make the transition from student to primary health care professional. Methods: Framework analysis methodology was used to analyze group opinion obtained using structured group feedback sessions. Sixty-eight final-year physiotherapy students from the four higher education institutions in Ireland participated. Results: The students identified several key areas that (1) supported their learning (exposure to evidence-based practice, opportunities to practise with problem-based learning, and interdisciplinary learning experiences); (2) were deficient (primary health care placements, additional active learning sessions, and further education and practice opportunities for communication and health promotion), and (3) required change (practice placements in primary health care, better curriculum organization to accommodate primary health care throughout the programme with the suggestion of a specific primary health care module). Conclusion: This study provides important insights into physiotherapy students' perceptions of primary health care. It also provides important indicators of the curriculum changes needed to increase graduates' confidence in their ability to take up employment in primary health care.

Child and adolescent psychiatry: which knowledge and skills do primary care physicians need to have? A survey in general practitioners and paediatricians

Primary care physicians (PCPs) play a key role in the initial assessment and management of children and adolescents with mental health problems. However, it is unclear whether current medical education curricula sufficiently equip PCPs for this task. The aim of this study was to investigate, which child and adolescent psychiatry (CAP)-related skills and knowledge PCPs say they require in their daily practice. A questionnaire was generated, employing a modified two-step Delphi approach. Besides socio-demographic items, the questionnaire contained 17 CAP-related knowledge items and 13 CAP-related skills items, which had to be rated by importance in daily practice. The questionnaire was distributed to 348 office-based paediatricians and 500 general practitioners (GPs) in Germany. The overall return rate was 51.3% (435/848). Regarding CAP-related knowledge, both paediatricians and GPs rated somatoform disorders and obesity as highly important for daily practice. Moreover, paediatricians also deemed regulatory disorders during infancy (e.g. crying, sleep disorders) as important, while GPs assessed knowledge on paediatric depression as relevant. For paediatricians and GPs, the most relevant CAP-related skills were communicating with children and adolescents and their parents. Additionally, paediatricians rated differentiating between non-pathologic and clinically relevant behaviour problems very relevant, while GPs considered basic psychotherapeutic skills essential. The CAP-related knowledge and skills perceived relevant for doctors in primary care differ from the majority of current medical school CAP curricula, which cover mainly typical, epitomic CAP disorders and are predominantly knowledge-oriented. Therefore, medical education in CAP should be amended to reflect the needs of PCPs to improve healthcare for children and adolescents with mental health problems.

A Latin American, Portuguese and Spanish consensus on a core communication curriculum for undergraduate medical education

BACKGROUND

To present learning outcomes in clinical communication for a Core Curriculum for medical undergraduate students in Latin America, Portugal and Spain (LAPS-CCC) and to establish an expert network to support a transnational implementation.

METHODS

Through an iterative process, an international group of 15 experts developed an initial set of learning outcomes following a review and discussion of relevant international and local literature. A two-round Delphi survey involving 46 experts from 8 countries was performed. Quantative and qualitative analisis permited the definition of the final consensus.

RESULTS

The initial proposal included 157 learning outcomes. The Delphi process generated 734 comments and involved the modification, deletion and addition of some outcomes. At the end of the process, a consensus was reached on 136 learning outcomes grouped under 6 competency domains with a high overall acceptance (95.1 %).

CONCLUSIONS

The learning outcomes of this proposal provide a guide to introduce, support and develop communication curriculae for undergraduate medical studies in the countries involved or in other Spanish- or Portuguese-speaking countries.

Training experts in family medicine teaching

Family medicine teachers require specific educational skills. A framework for their professional development is essential for future development of the discipline in Europe. EURACT developed a framework on educational expertise, and subsequently applied it in a curriculum of teaching-skills courses of various levels. The aim of this article is to describe the development of the teaching framework, and of an international three-level course programme for 'teaching-the-teachers'. Furthermore, we describe our experiences and lessons learned, in particular with regard to the level-three programme for proficient teachers, which was new. We conclude that it is possible to develop a theoretical framework of family medicine teaching expertise and to apply it in an international high-level educational programme for future experts in family medicine education. Research evidence of the usefulness of this approach is needed, and the threats for its further development into a sustainable activity are its high teacher/student ratio associated with relatively high costs and difficulties in recruiting suitable participants.

[Promotion of next generation primary care physicians: initiatives in the university training of medical students]

BACKGROUND

There is, and will be a serious shortage of young primary care physicians in Germany. Initiatives at medical faculties focusing on primary care may increase the recruitment of young primary care physicians.

OBJECTIVES

The present report describes national and international university initiatives, as well as programs for the recruitment of primary care physicians, and reports on their evaluation.

METHODS

We searched medical data bases, journals and the internet using corresponding key words in the sense of a pragmatic review article. We also contacted experts who were questioned on this topic.

RESULTS

Initiatives for increasing the recruitment of young general practitioners were identified at nine medical faculties in Germany. The underlying hypothesis of the existing programs is that the decision to become a primary care physician depends on the time point, extent and quality of the training at medical school. The decisive limitation of existing programs is that they have been sparsely evaluated. The available results from evaluations consistently indicate quite large positive effects on the recruitment rates; however, the underlying study designs are highly prone to bias.

CONCLUSION

The identified initiatives can be grouped into three different models: (1) postgraduate studies, (2) specialized curricula for selected students with high interest in primary care and (3) longitudinal integration of primary care teaching in the obligatory curriculum. Different aspects, such as selection of the curricular model, definition of content, reimbursement of personnel and material expenses as well as evaluation are relevant to the planning and implementation of such initiatives.

Recommendations for undergraduate training in the primary care sector--position paper of the GMA-Primary Care Committee

During their studies to become medical professionals, all students are obliged to become familiar with various aspects of primary care. The aim is to provide all students with a high quality training which ensures the best possible cooperation across all sectors of the medical system.

Primary care comprises the primary use of the medical service by an unfiltered set of patients as well as continued patient care – including home-care.

This position paper was developed together with representatives of the German Society of University Teachers of General Practice (GHA), the German Society for Ambulatory General Paediatrics (DGAAP), the German Society of General Practice and Family Medicine (DEGAM) and the German Society for Internal Medicine (DGIM).

It includes recommendations for teaching in the field of primary care in four different types of internships such as preclinical work experience (“Hospitation”), 4-week clinical traineeships of a casual nature (“Famulatur”) and 2-week courses of structured and assessed clinical training (“Blockpraktikum”) as well as a broad-based 4-month elective clinical placement in the final year (known as a practical year, “PJ”).

The recommendations encompass structural and process criteria for internships in different general practices.

In addition, for the first time recommendations for teaching on campus – in the fields of general medicine, paediatrics, numerous cross-sectional areas and other clinical fields, but also for clinical skills training – are set down here.

In this position paper the intention is to demonstrate the possible ways in which more aspects of primary care could be integrated into undergraduate medical training.

Undergraduate medical education in general practice/family medicine throughout Europe - a descriptive study

BACKGROUND

It is increasingly becoming evident that a strong primary health care system is more likely to provide better population health, more equity in health throughout the population, and better use of economic resources, compared to systems that are oriented towards specialty care. Developing and maintaining a strong and sustainable primary health care requires that a substantial part of graduating doctors go into primary care. This in turn requires that general practice/family medicine (GP/FM) strongly influences the curricula in medical schools. In the present paper we aim at describing the extent of GP/FM teaching in medical schools throughout Europe, checking for the presence of GP/FM curricula and clinical teaching in GP offices.

METHODS

A brief questionnaire was e-mailed to GP/FM or other professors at European medical universities.

RESULTS

259 out of 400 existing universities in 39 European countries responded to our questionnaire. Out of these, 35 (13.5%) reported to have no GP/FM curriculum. These 35 medical faculties were located in 12 different European countries. In addition, 15 of the medical schools where a GP/FM curriculum did exist, reported that this curriculum did not include any clinical component (n = 5), or that the clinical part of the course was very brief - less than one week, mostly only a few hours (n = 10). In total, 50 universities (19%) thus had no or a very brief GP/FM curriculum. These were mainly located in the Eastern or Southern European regions.

CONCLUSION

It is still possible to graduate from European medical universities without having been exposed to a GP/FM curriculum. The European Academy of Teachers in General Practice (EURACT) will launch efforts to change this situation.

Entrustable professional activities in family medicine

BACKGROUND

The Accreditation Council for Graduate Medical Education Outcome Project intended to move residency education toward assessing and documenting resident competence in 6 dimensions of performance important to the practice of medicine. Although the project defined a set of general attributes of a good physician, it did not define the actual activities that a competent physician performs in practice in the given specialty. These descriptions have been called entrustable professional activities (EPAs).

OBJECTIVE

We sought to develop a list of EPAs for ambulatory practice in family medicine to guide curriculum development and resident assessment.

METHODS

We developed an initial list of EPAs over the course of 3 years, and we refined it further by obtaining the opinion of experts using a Delphi Process. The experts participating in this study were recruited from 2 groups of family medicine leaders: organizers and participants in the Preparing the Personal Physician for Practice initiative, and members of the Society of Teachers of Family Medicine Task Force on Competency Assessment. The experts participated in 2 rounds of anonymous, Internet-based surveys.

RESULTS

A total of 22 experts participated, and 21 experts participated in both rounds of the Delphi Process. The Delphi Process reduced the number of competency areas from 91 to 76 areas, with 3 additional competency areas added in round 1.

CONCLUSIONS

This list of EPAs developed through our Delphi process can be used as a starting point for family medicine residency programs interested in moving toward a competency-based approach to resident education and assessment.