This year, 2023, marks the 50th anniversary of the establishment of family medicine as a discipline at the University of Alberta. In this article, we briefly reflect on the department’s history and achievements in education and research and clinical service.
Family medicine in Canada and the University of Alberta
In 1954, “following several years of deliberation, agitation, confrontation and activation by general practitioners across the country, the College of General Practice is founded”. These words not only characterized the early beginnings of general practice/family medicine in Canada but also characterize family medicine at the University of Alberta and in other universities today. The move from a hospital-based, rotating internship to an objectives-based residency program contradicted the convention that hospital-based medicine was all one needed to become an accomplished family physician.
In 1966, several three-year postgraduate training programs were established, one at the University of Western Ontario and one at the Calgary General Hospital (CGH). CGH was affiliated with the University of Alberta at that time. In 1967, the College of General Practice changed its name to the College of Family Physicians of Canada. The first certification exam in family medicine occurred in 1969.
By 1975, all but three of the 16 medical schools in Canada had CFPC-approved residency training programs. One of the three that did not have approved training in family medicine was the University of Alberta. In 1973, family medicine was still a division in the Department of Community Medicine and, in 1977, a free-standing division under the Dean of the Faculty of Medicine. In 1983, the division obtained departmental status, and Dr. Gerald Higgins was appointed the first Chair of the Department of Family Medicine. (Alberta Doctors Digest readers of a certain age may recall Dr. Higgins ably served as editor of our magazine for many years) The Department continued its growth under the leadership of Chairs Dr. David Moores (1990-2000), Dr. G. Richard Spooner (2000-2012), Dr. Lee Green (2012-2022) and Dr. Christina Korownyk, appointed most recently, in July 2023.
A primary challenge was the move from a hospital-oriented, service-directed rotating internship to a university- and community-based postgraduate educational program with defined educational objectives. The family medicine program was first established in 1973. By 1994, the program had become a single program in the CaRMS Match, and residents were internally matched to the three academic teaching sites at that time. The program has grown from 20 rotating interns in 1973 to more than 160 family medicine residents in 2023. The success of the residency program is attributed to the leadership of its directors: Dr. Gordon Chaytors (1990-1997), Dr. Paul Humphries (1998-2008, 2012-2014), Dr. Shirley Schipper (2008-2012), Dr. John Chmelicek (2014-2022) and recently appointed Dr. Michelle Morros (July 2022).
At the University of Alberta, the Department of Family Medicine offers enhanced skills training programs in addiction medicine, CFPC emergency medicine, care of the elderly, family practice anesthesia, palliative care, sport and exercise medicine, occupational medicine, and family medicine obstetrics. The CFPC’s recognition and support of special skills education and training represented its responsiveness to Canadian communities’ needs and those of the communities’ family physicians to provide a comprehensive array of generalist health services. It also represented the limitations inherent in a residency program of just two years duration.
Universities in Canada were slow to address the ongoing and emerging clinical needs of physicians in non-urban centres in Canada. In 1991, Dr. Richard Spooner was recruited to develop a rural program. Funding from the Rural Physician Recruitment and Retention Action established the Rural Rotation Program. The program funded rural preceptors to take on students. Currently, the University of Alberta has program sites in Edmonton, Red Deer, Grand Prairie and Yellowknife.
The foundation of undergraduate and postgraduate rural family medicine education depends on more than 38 rural-based family medicine practices in Alberta. The program in additional skills (surgery and obstetrics for physicians practicing in rural areas) would not have been possible without the guidance and assistance of Dr. Walter Yakimets of the Department of Surgery at the University of Alberta and colleagues in Grand Prairie.
The development of the Alberta Rural Physician Action Plan in 1991 provided a funding structure to support the special skills initiative, the undergraduate and postgraduate rural education programs and the recruitment and retention of physicians to rural Alberta (Rural Health Professions Action Plan, 2023). Supporting undergraduate and postgraduate learners based in rural settings for their education and training was key to successful outcomes.
Since the early 90s, the Department of Family Medicine’s contributions to undergraduate medical education have expanded significantly. The department is regularly characterized as “punching above their weight limit.” This is in recognition of the tremendous contributions made in all four years of undergraduate medical education and training. It is a clear reflection on the relatively small numbers of faculty in the Department contributing so very much.
The family medicine eight-week clerkship was formalized in 2008 with a doubling of the number of third- and fourth-year students. It is unclear why it took so long to realize that family medicine was a core clerkship, as important as surgery, internal medicine, pediatrics, psychiatry or obstetrics and gynecology. In 2013, the physicianship course was created by Dr. Amy Tan. It incorporated a much more robust communications curriculum as well as patient mentorship, academic service-learning program and longitudinal clinical experiences.
Pioneering contributions in medical education
Field notes
In the late 1980s, Dr. Michel Donoff initiated the documentation of feedback to residents through prescription-sized notepads, termed “field notes”. This laid the foundation for competency-based assessment in residency training evaluation. Field notes were developed as a mechanism for faculty preceptors/supervisors and residents to document progress toward meeting educational objectives. The in-training evaluation reports (ITERs) developed in the 70s often were completed at the end of rotations, with little or no evidence of ongoing supervision or coaching. Subsequently, field notes were adopted in most programs in Canada.
Rural integrated community clerkship (ICC) and pre-clinical network medical education (PNME)
Under the direction of Dr. Jill Konkin, the rural integrated community clerkship (ICC) was implemented in 2007-2008 to provide the opportunity for third-year medical students to complete the whole of that year in selected rural Alberta communities.
Through the Office of Rural and Regional Health, the pre-clinical networked medical education program (PNME) was implemented in 2010-2011. Under this program, select second-year undergraduate medical students spend four weeks of their GI block (from September to October) in a rural community providing them their first experience of clinical teaching. Both initiatives demonstrated the necessity and richness of using Alberta’s non-urban practices and educational opportunities for undergraduate medicine. The primary objective was to “immerse learners in generalist medical culture leading to an increase in the numbers of medical school graduates who choose generalist careers.”
Competency-based achievement system (CBAS)
CBAS is the overall framework for learner assessment in family medicine at the University of Alberta. Formative feedback is provided throughout training, as well as information contained in any tool for formative or summative assessments; all serve as the evidence base for summative decisions. A fundamental assumption of CBAS is the importance of continuity in education and assessment. Thanks to the efforts of Drs. Mike Donoff, Paul Humphries, Darren Nichols, Shelley Ross and Mirella Chiodo for the development, maintenance and dissemination of this nationally and internationally recognized program.
Patients, Experience, Evidence and Research (PEER)
PEER is a primary-care-led, evidence-based medicine team focused on providing relevant evidence to family physicians and primary health care providers. It evolved from the initiatives of Drs. Mike Allan, Tina Korownyk, Mike Kolber, Jessica Kirkwood and Scott Garrison. This group was responsible for one of the most successful and practical undergraduate and postgraduate programs in the Faculty of Medicine. PEER evolved from the curiosity of a small group of family physicians into a team of primary care providers who are engaged in evidence-based medicine research.
Quality and safety in family medicine/primary care and quality improvement
In 2014, under the leadership of Mirella Chiodo and Dr. David Moores, the residency program adopted educational objectives for the teaching of quality and safety in family medicine/primary care, representing one of the first such initiatives in Canada. Using the British concept of “significant events,” residents were required to document a minimum of three significant events during their program and analyze them. A significant event is anything anybody on the health care team, including patients and their families, see as important in the quality of care or the conduct of the practice. Residents are encouraged to use a significant event as a basis for their required quality improvement project. Hospital-oriented reporting and learning systems rarely identify and address the significant events that occur at in the interfaces of health services.
Research and scholarship
Research and scholarship have grown substantially with respect to the number of faculty, from four academic faculty members in 1973 to nine in 1990s and now to 38. Under the direction of research directors Dr. Neil Bell (1983-1994), Dr. Andrew Cave (1994-2006), Dr. Donna Manca (2006-2022) and recently appointed (July 2022) co-directors Dr. Ginetta Salvalaggio and Andrea Gruneir, the Department has now a proven track record of research and scholarship.
Summary
The department’s goal is to ensure through all activities that Alberta has a well-integrated, primary-care-based health care system in which all citizens have access to a family physician who provides timely, proactive, individualized, comprehensive and continuous care through an interdisciplinary team of health care professionals. They produce scholarly work to teach the discipline of family medicine and to improve clinical practice and primary health care. Thus, we are able to better address the needs of our society.
The Department of Family Medicine recognizes the contributions of many family physicians practicing in rural, regional and urban Alberta, as well as the family physicians and specialists who took responsibility to supplement core family medicine education and training with enhanced skills. For those contributors who have not been specifically mentioned in this reflection, sincerest apologies are offered.
Editor’s note: There is so much achievement in our province. We are pleased to help share stories of success. We welcome suggestions for profiles or stories marking milestones and accomplishment.
References available upon request