Identifying public health competencies relevant to family medicine.

Public health situations faced by family physicians and other primary care practitioners, such as severe acute respiratory syndrome (SARS) and more recently H1N1, have resulted in an increased interest to identify the public health competencies relevant to family medicine. At present there is no agreed-on set of public health competencies delineating the knowledge and skills that family physicians should possess to effectively face diverse public health challenges. Using a multi-staged, iterative process that included a detailed literature review, the authors developed a set of public health competencies relevant to primary care, identifying competencies relevant across four levels, from "post-MD" to "enhanced." Feedback from family medicine and public health educator-practitioners regarding the set of proposed "essential" competencies indicated the need for a more limited, feasible set of "priority" areas to be highlighted during residency training. This focused set of public health competencies has begun to guide relevant components of the University of Toronto's Family Medicine Residency Program curriculum, including academic half-days; clinical experiences, especially identifying "teachable moments" during patient encounters; resident academic projects; and elective public health agency placements. These competencies will also be used to guide the development of a family medicine-public health primer and faculty development sessions to support family medicine faculty facilitating residents to achieve these competencies. Once more fully implemented, an evaluation will be initiated to determine the degree to which these public health competencies are being achieved by family medicine graduates, especially whether they attained the knowledge, skills, and confidence necessary to effectively face diverse public health situations-from common to emergent.

Introduction

Events such as severe acute respiratory syndrome, and more recently H1N1, are examples of public health situations faced by family physicians and other primary care practitioners. These events, in conjunction with other public health issues such as vaccine-preventable infections and rising rates of obesity and the associated health challenges, have resulted in an increased interest in the interface between primary care and public health (e.g., the IOM's consensus study) and in better identifying public health competencies relevant to family medicine so that family physicians and other primary care practitioners might better appreciate the population-wide perspectives of public health issues. However, at present there is no agreed-on set of public health competencies that family physicians and other primary care practitioners should attain to better ensure they possess the necessary knowledge, skills, and confidence to effectively face diverse public health situations—from common to emergent. Using an iterative consultative process, the authors developed a set of public health competencies relevant to family medicine and primary care.

The Initial Development Process

This process began with planning for a 1-day, pan-Canadian, family medicine–public health symposium that was held in March 2008. This symposium arose out of discussions at the pan-Canadian Public Health Human Resources Task Force concerning the role of primary care practitioners in Canada's public health workforce. The primary goals of the symposium were to identify: (1) the public health competencies that family medicine residents should possess at graduation; and (2) the primary care competencies that community medicine residents should possess at graduation. To help address these goals, a presymposium discussion document was prepared by reviewing existing documents to develop an initial competency draft using a “multi-level competency model” developed by the University of Toronto's Department of Family and Community Medicine. The resources accessed and reviewed to inform the preparation of the presymposium discussion document included:

the College of Family Physicians of Canada's The Role of the Family Doctor in Public Health and Emergency Preparedness ;

the Medical Council of Canada's undergraduate medical education objectives, particularly the seven addressing “Population Health”;

the Royal College of Physicians and Surgeons of Canada's Objectives of Training for the medical specialty of community medicine;

the Core Competencies for Public Health in Canada that were developed in partnership with the Public Health Agency of Canada;

The medical discipline–specific Minimum Competencies for Medical Officers of Health (i.e., public health officers) that were developed under the sponsorship of the Public Health Agency of Canada;

the Accreditation Council on Graduate Medical Education (ACGME) statement regarding the community medicine objectives required in family medicine residency programs;

the ACGME statement regarding the requirements for residency programs in public health and general preventive medicine.

A search of the literature, coupled with suggestions from individuals consulted, identified several other relevant and informative Canadian,9, 10 American,11, 12, 13, 14, 15 British,16, 17, 18 and Australian19, 20, 21 publications. These were also reviewed and assisted the development of a draft set of public health competencies relevant to family medicine and primary care.

Four levels of competencies were drafted, following the model developed in Toronto's Department of Family & Community Medicine, which spans resident-readiness (expected of all MD graduates), essential (expected of all family medicine graduates), enriched (achievable by most residents during family medicine residency training), and enhanced (achievable only through additional training after the family medicine residency).

Following the review of existing documents and preparation of the presymposium discussion document, the authors identified and used eight themes to guide the development of the draft set of competencies. These eight themes were:

disease prevention and health promotion;

infectious disease prevention and control;

emergency preparedness and response;

environmental health;

systems thinking, public health leadership, and management;

population health assessment;

policy, planning, communication, collaboration, and advocacy;

scholar and educator.

Reviewing and Revising the Proposed Draft Competencies

A variety of family medicine and public health educator–practitioner colleagues reviewed and provided feedback concerning the proposed draft set of competencies. The first group of reviewers was the 24 program directors and residents who participated in the March 2008 pan-Canadian Family Medicine–Public Health 1-day symposium. This group included 12 residency directors (six family medicine, six community medicine) and 12 residents (six family medicine, six community medicine) from across Canada. The presymposium discussion document, which included a proposed set of draft competencies, was distributed to the participants for their review prior to the symposium. The draft competencies served as the major item for discussion by the participants during the symposium's plenary and small group discussions. Symposium discussions enabled the authors to further revise the discussion document and proposed set of competencies. This revised draft was then sent to all symposium participants for additional review and feedback, which resulted in the proposal of a detailed set of public health competencies relevant to family medicine and primary care (Appendix B, available online at www.ajpmonline.org).

This detailed set of competencies was presented at the October 2009 Family Medicine Forum, Canada's annual family medicine conference. Feedback received from conference participants suggested further revisions to the competency draft, particularly the need for a more limited, feasible set of “priority” areas to be focused on during residency training, especially because of the limited duration of family medicine residency training programs—being only 2 years in Canada and 3 years in the U.S.

As a result, the authors sought further feedback from interested family medicine and public health practitioner–educators and residents from across Canada to identify a more focused set of priority areas to be emphasized during residency training. These colleagues were asked to rank-order the public health competencies that they considered essential for any graduating family medicine resident. With this advice, the authors identified a priority list of eight competency areas:

the basic fundamentals of outbreak/emergency preparedness and management;

office infection control;

infectious disease reporting and management;

environmental health exposure reporting;

public health aspects of immunization;

public health programs applicable to primary care (e.g., maternal–child health);

addressing and managing one's practice as a population (e.g., developing practice health profiles and using quality assurance to increase the delivery of preventive services);

the principles and practices of screening (i.e., early detection and treatment) of diseases.

Final Departmental Review and Revision

Public health is only one of 14 competency domains in the University of Toronto's Family Medicine Residency Program's recently developed competency-based curriculum (other domains include child health, women's health, and mental health). To ensure the overall coherence of the 14 proposed sets of competencies, a full review was completed by a diverse group of 35 family medicine leader–educators at a departmental retreat in April 2010. A key finding arising from this review was that only focused, essential competencies could be realistically identified within each of these 14 domains. This resulted in five public health competencies being identified and approved for inclusion in the competency-based residency curriculum, each accompanied by one or more enabling subcompetencies. These five overarching public health competencies are:

demonstrate an effective approach to disease prevention and health promotion;

demonstrate an effective approach to infectious disease prevention and control, including outbreaks;

demonstrate an effective approach to environmental health issues;

develop and apply the knowledge and skills necessary to assess a population's health;

demonstrate an effective approach to public communication, collaboration, and advocacy.

This more focused set, with the accompanying enabling competencies and a listing of suggested relevant topics for each, is included in Appendix A. It should be noted, however, that the more extensive complete set of public health competencies relevant to family medicine (Appendix B, available online at www.ajpmonline.org) is expected to continue to serve as the comprehensive listing to complement the more focused set of essential competencies and as the primary listing of the enriched and/or enhanced public health competencies relevant to family medicine and primary care.

Conclusion

The focused set of public health competencies approved by the University of Toronto for family medicine (Appendix A) has begun to guide its Family Medicine Residency Program curriculum, including resident seminars; family medicine clinical experiences, especially identifying teachable moments that occur during patient encounters; elective public health agency placements; and topics selected for the required resident research project (e.g., the prevalence of chlamydia, a profile of those infected with H1N1 influenza). These competencies will also be used to guide the development of a Family Medicine public health primer that would complement the Association of Faculties of Medicine of Canada's Primer on Population Health developed for medical students, and faculty development sessions to support the family medicine faculty facilitating residents in their achievement of these competencies.

Once it is more fully implemented, an evaluation will be initiated to determine the degree to which these public health competencies are being achieved by family medicine graduates, especially whether they attained the knowledge, skills, and confidence necessary to effectively face diverse public health situations—from common to emergent. It is anticipated that the experience gained through the implementation of the proposed set of competencies (and their evaluation), at the University of Toronto and other family medicine residency programs where they are implemented, will provide evidence of the utility and suitability of the proposed competencies and of further revisions that might be warranted.