Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study

INTRODUCTION

Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care.

METHODS AND ANALYSIS

In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events.

ETHICS AND DISSEMINATION

We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

Remediation in Canadian medical residency programs: Established and emerging best practices

BACKGROUND

Policies to guide remediation in postgraduate medical education exist in all Canadian medical schools. This study examines concordance between these policies and processes, and published "best practices" in remediation.

METHOD

We conducted a literature review to identify best practices in the area of remediation. We then reviewed remediation policies from all 13 English medical schools in Canada other than our own and conducted interviews with key informants from each institution. Each policy and interview transcript pair was then reviewed for evidence of pre-defined "best practices." Team members also noted additional potential policy or process enablers of successful remediation.

RESULTS

Most policies and processes aligned with some but not all published best practices. For instance, all participating schools tailored remediation strategies to individual resident needs, and a majority encouraged faculty-student relationships during remediation. Conversely, few required the teaching of goal-setting, strategic planning, self-monitoring, and self-awareness. In addition, we identified avoidance of automatic training extension and the use of an educational review board to support the remediation process as enablers for success.

DISCUSSION

Remediation policies and practices in Canada align well with published best practices in this area. Based on key informant opinions, flexibility to avoid training extension and use of an educational review board may also support optimal remediation outcomes.

Understanding, teaching and assessing the elements of the CanMEDS Professional Role: canadian program directors' views

BACKGROUND

Physicians are required to maintain and sustain professional roles during their careers, making the Professional Role an important component of postgraduate education. Despite this, this role remains difficult to define, teach and assess.

OBJECTIVE

To (a) understand what program directors felt were key elements of the CanMEDS Professional Role and (b) identify the teaching and assessment methods they used.

METHODS

A two-step sequential mixed method design using a survey and semi-structured interviews with Canadian program directors.

RESULTS

Forty-six program directors (48% response rate) completed the questionnaire and 10 participated in interviews. Participants rated integrity and honesty as the most important elements of the Role (96%) but most difficult to teach. There was a lack of congruence between elements perceived to be most important and most frequently taught. Role modeling was the most common way of informally teaching professionalism (98%). Assessments were most often through direct feedback from faculty (98%) and feedback from other health professionals and residents (61%). Portfolios (24%) were the least used form of assessment, but they allowed residents to reflect and stimulated self-assessment.

CONCLUSION

Program directors believe elements of the Role are difficult to teach and assess. Providing faculty with skills for teaching/assessing the Role and evaluating effectiveness in changing attitudes/behaviors should be a priority in postgraduate programs.