Needs-assessment
All of the three 2014 FD initiative learners agreed to participate in the needs assessment
interviews. Participants wanted to learn mainly about educational theories, educational
skills, educational framework, management skills, as well as a few practical business
skills (e.g. work-life balance, anger management skill). They described high workload
and lack of time for the program participation as two major challenges. As for the
career direction of the participants, two of them were seeking clinician educator
positions at a community hospital or a clinic, and another learner wanted to obtain
an academic position at a university.
Faculty Competencies
Seven faculty physicians working in the residency-affiliated hospitals and clinics
participated in the Delphi process. After the four-round Delphi process, we defined
28 objectives under five core domains: 1) care management and family medicine principle,
2) leadership and professional development, 3) administrative and management skill,
4) teaching, and 5) research and scholarly activity (Table 2). The two-year curriculum
was structured with two to three didactics a month, course assignments (e.g. video
precepting, individual project work), and supervised writing of course portfolios.
From April 2016 to March 2017, we held 20 educational sessions with three learners
(Table3).
Focus Group Interview
Three learners agreed to participate in the focus group and the subsequent survey.
The focus group results were analyzed and articulated in five main themes:
1) foundational soil, 2) seedbed, 3) sowing of seeds, 4) nurture and growth, and 5)
reaping the harvest (Figure 2).
Theme 1: Foundational soil
-Ambiguous mastery of domain 1 (family medicine principle):
“For other competency domains, it was very easy to understand what we had learned
through a combination of theory and work. But I found the domain 1 had more ambiguous
concepts, which made it hard for me to grasp what I had gained.”
-Low priority of domain 1 (family medicine principle) for some learners:
“Considering that the amount of competencies we have to learn is a lot, and that we
already have learned a certain amount of the domain 1 through the board exam, this
area can be reduced for next year's curriculum.”
-Positive effect of domain 1 (family medicine principle):
“Domain 1 was helpful as an opportunity to reflect on myself.”
-Usefulness of domain 1 (family medicine principle) from the clinician's perspective:
“Domain 1 was quite important to me. Suffering and healing are difficult topics in
daily practice. I have a sense that I may got a clue to understand those things. It
was helpful for me as a clinician, not even as a faculty. This experience made me
happy to be a family physician.”
Theme 2: Seedbed
The learning process of FD participants was largely influenced by learner characteristics
and their context.
Sub-theme: Independent & autonomous learners
-Self awareness that one should be independent and autonomous as a learner:
“The FD program gave us seeds by suggesting topics and references. It is the learners'
responsibility to nurture the seed.”
“After learning new concepts, you will also be encouraged to continue learning by
yourself.”
Sub-theme: Background factors affecting understanding of the topic
-Practice opportunities and the degree of interest for each topic:
“In terms of understanding, there is quite a difference in the degree of comprehension
in each competency and domain. It depends on how relevant and familiar the topic is
for your current practice and also the level of interest you have.”
-Lack of relevance, lack of basic knowledge, less practical opportunities:
“My understanding about topics that are not relevant to me, such as research, was
not that much improved. I think that it is different from my previous level of understanding,
though.”
“I had no basic knowledge about management, so I had to start with a blank slate.
In addition, as I did not have opportunity to deal with it after the session, I forgot
what I had learned very soon thereafter.”
Theme 3: Sowing of seeds
Sub-theme: Useful aspects of the strategy taken
-Interactive learning:
“It was great to learn in an interactive way, including work-shopping and outside
of class experiences.”
-Combination of didactics, work-shopping, and outside of class experiences:
“Learning through concurrent elements of the program was effective for me.”
-Effective curriculum design:
“It was a very efficient program with a mechanism that allows each theme to be related.
Each previous session was related to the next one.”
-Well-prepared sessions:
“Through all the sessions, handouts were sophisticated and sessions began by trying
to understand the basic concepts. I felt the teaching style really matched my learning
style and it was a lot of fun.”
Sub-theme: Suggestions for the improvement of curriculum
-Not sure if the topics should be taught simultaneously vs. block by block:
“I don’t know if teaching the core competency domain 1 - 5 simultaneously compared
to doing them one by one is more effective.”
-Areas should be concurrently parallel:
“Annual scheduling is very difficult, but I think that it would be better to do all
the areas simultaneously.”
-Implementation of topics that will lead to project works in each area earlier in
the academic year:
“I think it would be ideal if we could complete projects in each of the 5 domains
by the end of a year. What about doing topics that will lead to project works in each
area earlier in the academic year?”
-Follow-up assignments will not be needed:
“Sufficient preparation makes the session meaningful. I do not think we need to have
follow-up assignments.”
-Follow-up assignments were useful for review:
“I had struggled with the follow-up assignments, but it helped. It helped refreshing
my memory through the review process.”
-Follow-up assignments that link to the next session would be useful:
“It would be great if the follow-up assignments nicely linked to the next session.”
-It is desirable to evaluate each unit more frequently:
“The evaluation could be distributed more frequently for each unit. I felt I had some
thoughts about the session but have completely forgotten as of now.”
Sub-theme: Sense of burden
-Imbalance between personal capacity and task volume:
“Catching up with assignments, especially follow-up assignments, was hard for me.
For some nights before FD sessions, I had to stay up late.”
Sub-theme: Contents that were useful
-Leadership and personal growth, administrative and management skills, especially
with regard to how to operate a clinic:
“Leadership and personal growth, administrative and management skills, and especially
the topic regarding clinic operation were very new to me. I felt I learned a lot in
these areas.”
-Practical educational skills, writing a letter to the editor session:
“Sessions on practical educational skills and the research opportunity such as the
letter to the editor session were very interesting.”
Theme 4: Nurture and growth
Sub-theme: Relationship between the growth and soil
-Compatibility between learner's position and theme:
“Sometimes the topic did not necessarily suit me since I was a graduate student.”
-Difference in learning objectives based on theme compatibility:
“Even for topics that did not suit my interest, there were always some tips for my
previously unsolved problems.”
“Basically, there was nothing negative. I could always find something positive.”
-Consistency of courses and competencies through practice:
“Competency is derived not from armchair theory but from actual problems confronted
by previous faculty. I believe I can learn them by pursuing the current curriculum.”
-Learners are responsible for interpreting and utilizing the contents:
“Looking back, maybe I have been trying to interpret, understand, and apply what I
had learned to practical work on myself.”
Sub-theme: Variation in understanding of individual topics
-Core concepts of family medicine, sharing decisions, mind skills of education:
“I was able to gain a deep understanding about core concepts of family medicine, sharing
of decision, and educational mind skills—as well as some understanding on how to apply
them.”
-Conference facilitation and management skills, financial analysis:
“As for the conference facilitation, management skills, and financial analysis, I
could not fully comprehend these topics.”
Sub-theme: Difficulty of behavioral changes
-Difficulty of internalizing the knowledge at a practical level:
“If the goal is to simply acquire knowledge, it can be achieved once I know it. It
is more difficult to actually internalize the knowledge at a practical level.”
“When I hear about various existing theories, I feel ‘oh, that's right.’ When I try
to apply it that I realize the gap between ‘knowledge’ and ‘wisdom.’”
Sub-theme: Themes that did not lead to behavioral changes
-Logical Thinking, Financial Relationship, Vision, Research:
“Logical thinking was also my favorite theme. I could understand to a certain extent,
but it was difficult to change my behavior based on that.”
“I couldn't make any behavioral changes concerning finance topics and the shared vision
session. Research is actually the most relevant theme but I could not proceed.”
Sub-theme: Insufficient understanding
-Feeling of insufficient understanding:
“My concern is that I may not have fully digested what was taught to us during the
course and that I may not be able to apply those lessons to the practice in the future.”
“Obviously, there were several topics that I could not fully comprehend compared to
the others.”
Theme 5: Reaping the harvest
Sub-theme: Explicit behavioral change
-Incorporating patient narrative into practice, Shared-Decision Making, Time Management:
“Since the fellowship sessions, I noticed that I have been conscious about the patient
narrative and the shared-decision making model during patient encounters. The concept
of time management is deeply implemented in my real life, as well. I don't know if
those are successful changes, but my behavior has certainly changed.”
-Able to talk about leadership and management:
“Now I can discuss with various people about topics that I was not familiar with before,
such as leadership, management, and organizational management.”
-The threshold for QI and research has fallen:
“By learning the basics of, let's say, quality improvement and research, I felt I
wanted to try them since they seemed easier than before. I also found myself thinking
"oh this might be a good fit for a QI project!" and things like that. It is such a
big change.”
-Applying feedback to their learners:
“Changes I've noticed in my behavior… The most explicit one is the educational skill.
We have learned various ways of giving feedback, including what kind of feedback is
appropriate for particular types of learners. And I've brought them back to apply
to myself.”
-Time Management, Logical Thinking:
“Several other things, such as the time management and logical thinking, were easy
to understand and I feel I am using them a little bit in my daily life.”
Sub-theme: Awareness of transferability of FD competencies
-Awareness of transferability of FD competencies:
“I noticed that such FD competencies can be applied to other jobs and professions,
not only the medical field. Of course to private life as well. Such as in the case
of conflicts with family members.”
Sub-theme: Awareness of growth through FD
-Confidence and joy about learning the strategies of lifelong learning:
“As a part of lifelong learning, it was helpful to learn how to learn after you finished
the residency training. That made me feel confident and happy.”
-Realization of skill up through FD:
“Seeing the competency list for the first time in a while, I felt that we had learned
a lot. I can see myself being a bit more skillful and being confident by attending
this curriculum.”
-Confidence by knowing new knowledge, way of thinking, framework etc.:
“I felt confident in the sense that I was able to know the idea that was not in my
own thought process before, such as new knowledge, thoughts, and frameworks.”
Sub-theme: Significance of FD
-A feeling of security for the presentation of directions of lifelong learning:
“I felt secure for being taught a path, which would be better to have as a faculty.
It was helpful to be able to learn how my seniors had grown up.”
-The FD program gave us seeds by providing themes, topics, and references:
“By suggesting potential themes, topics, and references, the program gave us seeds
for which we can nurture later.”
-Dialogue as a means of internalizing knowledge:
“I think another aspect of FD is that we can proceed without becoming self-righteous
while having dialogues with great predecessors.”
“We need mentors to avoid being self-satisfied.”
“It is worthwhile to know what I do not understand.”
A pre-post confidence level survey
A pre-post survey revealed significant increase in learner confidence level for domains
“Care Management / Family Medicine Principle” (p=0.03), “Teaching” (p<0.01), and “Research
/ Scholarly activity” (p<0.01), as well as the total score (p=0.03) (Table 4).