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Internationally, I continue to be proud of our work on the Toronto Addis Ababa Academic Collaboration

—Dr. Lynn Wilson

Faculty and Staff Travel 30,000 km across Ontario to Support Rural Preceptors and Residents

When thinking about family medicine at the University of Toronto, DFCM’s affiliated teaching hospital sites in and around the Greater Toronto Area are often the first that come to mind.

Yet, DFCM includes more than 30 community-based teaching sites throughout rural Ontario that make up its rural residency and teaching practices programs. 

There are several ways family medicine residents at DFCM can gain experience practising in rural communities. The Teaching Practices program provides a two-month rural placement as part of the PGY2 year in the Family Medicine curriculum, where the residents are exposed to the opportunities, challenges and rewards of practising in rural communities. Our residents can choose to enrol in the Rural Residency Stream that allows them to spend the entire second year of their family medicine training in Midland, Orillia, Port Perry or Orangeville.

Ensuring that rural preceptors feel supported and engaged with DFCM can pose logistical challenges, because they are distributed at sites from as far east as Kincardine, as far west as Campbellford and as far north as Red Lake (about a six-hour drive from Thunder Bay).

That is why Dr. Erika Catford, Director of the Teaching Practices Program; Dr. Gwen Sampson, the professional development representative for Teaching Practices; and Fadia Bravo, the Teaching Practices Program Assistant, headed out on a two-week, 30,000 kilometre faculty development tour in the summer of 2016 that included conducting workshops for 95 preceptors in 22 communities.

Faculty at each site had the opportunity to select from a list of seven accredited MainProC Practice-Based Small Group (PBSG) learning modules. The workshops were selected based on the faculty's needs, including topics such as providing feedback to learners; interprofessional education and collaboration; and time-efficient teaching strategies. During the visit, preceptors were also able to update their practice profiles.

“We’ve conducted many efforts to engage with our rural preceptors online; however, we have found that face-to-face visits have so many long-term benefits that the travel is worth it,” says Dr. Sampson, who also practices in Stouffville.

This isn’t the first time a tour of this nature has been undertaken. In 2012, the team visited more than 23 rural sites to create a video profile of each practice and community. These videos are used to provide residents with the opportunity to review their options and make the best decision before selecting their choices for the Teaching Practices matching process.

Watch our Teaching Practices Virtual Site Tour and learn more about our rural sites.

Coming Together to Deliver Health Care to Syrian Refugees

In late 2015, when DFCM faculty member Dr. Perle Feldman heard she would be seeing a recently arrived Syrian refugee with cancer, she knew she would have to act fast. The man had been undergoing treatment in Beirut, Lebanon, after moving there from a refugee camp, but he desperately needed surgery.

“By the time he arrived in Canada he already had undergone two to three more cancer treatments than he should have – he was weak,” says Feldman, a family physician at North York General Hospital.  “He was on the plane Thursday night and I saw him Friday afternoon – it was quick.”

Feldman completed the initial physical exam and immediately called Princess Margaret Hospital. She was able to get to the right surgeon almost instantly. Within five days of arriving, the patient was finally able to start proper treatment.

“I didn’t do anything for my Syrian refugee patient that I wouldn’t have done for a Canadian-born patient, but if he had been living in Canada, he would have received proper and faster treatment from the beginning,” said Feldman.

Though extreme, stories like this demonstrate the need for refugees — Syrian or otherwise — to see a family physician for a general exam after arriving in Canada. While refugees are screened for infectious disease overseas, underlying medical conditions and chronic diseases may be missed.

Before the main influx of Syrian refugees to Canada began in 2015, Dr. Meb Rashid, a family physician at Women’s College Hospital, began to lead the response by primary care providers across the Greater Toronto Area, where the majority of Canada's  25,000 new Syrian refugees would be settled.

It was not an easy task: Dr. Rashid and his team co-ordinated with various family medicine health teams at hospitals and clinics across the Greater Toronto Area (GTA) — including nearly all of DFCM’s academic teaching hospital sites — to develop rotating intake clinics where family physicians could see refugees for initial assessment.

More than a year later, with refugees still coming to the clinics — though, now in lower numbers — Dr. Rashid can reflect on the response and the things that went well and those that could have been done better.

“Looking back and to this day, I remain inspired by the sheer willingness and enthusiasm of clinicians to contribute to the health-care response,” says Dr. Rashid. “The reactions to our requests were incredible. Many family doctors and health-care professionals donated time and expertise to these clinics on top of their regular clinical demands." 

The clinic saw a large influx of Syrian refugee patients throughout January and February 2016 when the vast majority arrived in Canada. The steady stream of new and returning patients, including family members of refugees who continue to arrive, has since simmered down.

The majority of the conditions seen at the clinics are fairly common problems, including iron deficiency, dental issues, chronic diseases like diabetes and hypertension, pregnancy and some mental health challenges. Many children coming to the clinic also needed updates to their vaccinations because access to health care has been erratic in Syria during the past several years. Rashid admits that clinics saw and continue to see more privately-sponsored Syrian refugees than government-sponsored refugees. This is largely, organizers conjecture, due to logistics; many government-sponsored refugees were housed in hotels at the periphery of the city, making it more difficult to connect with people.

“Privately-sponsored refugees tend to have sponsors that ensure families get connected to primary care,” explains Dr. Rashid. “The government-sponsored refugees we saw tended to have more challenges accessing clinics. There was a bottleneck at many of these hotels as they’re dealing with so many other logistics. We eventually began to see them trickle in over time.”

Dr. Ashna Bowry, a DFCM researcher and family physician at St. Michael’s Hospital Academic Family Health Team, is leading the research on the health of Syrian refugees. Currently, she and her colleagues are retrieving the data from the various sites that treated refugees to see what types of health issues the clinics addressed and understand the challenges they faced. It’s hoped that the lessons learned will add to the literature about refugee health in Canada and provide a guide for other health-care professionals treating refugees in Canada and around the world.

“Looking back, and to this day, I remain inspired by the sheer willingness and enthusiasm of clinicians to contribute to the health-care response,” says Dr. Rashid. “The reactions to our requests were incredible. Many family doctors and health-care professionals donated time and expertise to these clinics on top of their regular clinical demands."

—Dr. Meb Rashid

Dr. Rashid says there are many lessons to be learned but he’s proud of the response to the crisis by health-care professionals in and around the GTA.

“I remain inspired by how we pulled together to address this migration,” says Dr. Rashid. “We saw many clinicians who generally don't have an opportunity to see refugees participate in the health-care response to the Syrian migration. We also have more family physicians and other health-care professionals who might not often treat newly-arrived refugees who are now more comfortable doing so. Undoubtedly, this will help better serve future refugee migrations.”

Profiles of Academic Fellows from The Academic Fellowship and Graduate Studies Program

DFCM's Academic Fellowship and Graduate Studies program offer many opportunities for health-care professionals at all levels to advance their careers and become leaders in their respective fields. Whether you want to broaden your education and teaching skills, get involved in health system leadership, begin or advance your career in public health or become a primary care researcher or scholar – there are many avenue to pursue leadership opportunities. Below, two AFGS alumni discuss how their education impacted their careers

Dr. Montaser Bukhamseen Family Medicine Consultant, Ministry of Health, Saudi Arabia

How would you describe your experience in the Fellowship program?

The Academic Fellowship had a unique and impressive methodology and process, which combined the spirit of family medicine and the passion of medical education. The program had a great impact on my clinical and teaching career as family physician and trainer. It expanded my skills in research and quality improvement in primary health care. It also introduced me to new concepts in dealing with my patients and their families.  

How would you say the program has influenced your career?

The training in the fellowship with its various content, approaches, and its multicultural, caring, and supportive environment had great influence on my personal and professional life. Since I came back, I have been working as accreditation team leader on upgrading the postgraduate study in family medicine in our department from two-year diploma to full four-year residency program. I have tried to utilize the principles and various medical education methods I had been taught in the fellowship to gain the accreditation. The fellowship also introduced me to the quality in health-care world and the course of quality improvement in primary care facilitated my involvement in the Saudi central board for accreditation of a health-care institution (CBAHI) as a surveyor.

Why would you recommend this program to other health professionals?

Because of its informative content, inspiring instructional method and quality of organization, I will strongly recommend it to all health-care professionals, particularly those who are involved in medical teaching or training at undergraduate or postgraduate level.

Karen Weyman Chief of Family Medicine, St. Michael’s Hospital

How would you describe your experience in the program?

I participated in the program in its early stages. Our teachers were leaders in our Department, such as Drs. Walter Rosser, Helen Batty, Sudi Devanesen and Yves Talbot. It was fantastic for someone like me just finishing residency to be exposed to so many great family medicine thinkers and leaders. It gave me the opportunity to get to know these leaders within the Department and learn from them, which was quite a privilege.

The academic fellowship was an exciting year of learning. I found it also gave me access to many future mentors. Suddenly, you are connected with a group of people who have similar interests to yours – whether the practice of family medicine, teaching or research – and a group of teachers who encourage and inspire you to reach your potential that you didn’t even realize was possible.   

I also met a lot of people beyond members of the DFCM. Many of the peers I interacted with were not family physicians or from the University of Toronto and it was great to learn from each other. It’s so valuable to hear different perspectives and work with others outside your discipline. I met people who shared a passion for medical education, which ultimately led me to complete my Master’s degree in Higher Education at OISE.  I also met some wonderful colleagues and friends during the academic fellowship, including my wonderful husband.  

How did advancing your education influence your career?

Beyond becoming so much more knowledgeable about medical education and confirming that I wanted to pursue a career in academic medicine, both my Master’s degree and the academic fellowship opened a lot of doors for me. I did my fellowship through Toronto General Hospital where I did my residency and, ultimately, it was a connection through a course I took that led to an offer of a full-time position at St. Michael’s where I have worked for the past 24 years. The academic fellowship and Master's in Education gave me a new way of thinking about academic family medicine and has continued to influence my career as a clinician, teacher and educator.

Would you recommend the program to others?

In my current role as Chief, I mentor people to think about what it means to be an academic family physician and what knowledge and skills they need to reach their goals. The DFCM's Academic Fellowship and Graduate Studies program is an excellent base to start or enhance one’s academic career and learn more about family medicine, medical education, teaching and research. It was worth it for me.

In your role as Vice-Dean, Partnerships, what is the main focus or priorities for partnerships within the Faculty of Medicine?

The Dean’s Report sets out three main priorities for the Faculty of Medicine at University of Toronto: Prepare, Discover and Partner. Within that, my team and I strategically focus on three fronts: system transformation, health innovation and a powerful international brand. It’s important to acknowledge that all of our faculty leaders are deeply engaged in developing and sustaining strategic partnerships. At times, my office takes the lead in these initiatives, but much of the time, we provide support for and/or promote activities carried out by others.

For instance, under the theme of Prepare, we’re exploring partnerships both within and outside the University that will help educate physicians of the future in really innovative ways. A good example of this at the University of Toronto is the new Computing for Medicine elective course for MD students. This is the result of a partnership between our MD program and the Department of Computer Science and was created by a DFCM faculty member, Dr. Marcus Law [the Director of Preclerkship Renewal and Academic Innovation at the University of Toronto’s Faculty of Medicine]. Dr. Law recognized that future physicians who want to develop technological solutions for our health-care system will need to be able to understand and speak to technology developers. The first year of the course was completely full. It just shows that we don’t necessarily have to seek partnerships externally to be innovative.

We also are focusing on partnerships for research and innovation. For example, our Masters of Health Science in Translational Research lies within the Institute of Medical Science but includes affiliations with many departments, hospitals, programs and teaching hospitals.

Internationally, I continue to be proud of our work on the Toronto Addis Ababa Academic Collaboration and our incredibly fruitful collaboration with the Karolinska Institute in Sweden. More recently, this partnership includes the Mats Sundin Fellowship, which supports collaboration between researchers at both institutions to investigate questions related to early childhood development. I anticipate many advances to come from this fellowship. More recently, our Department of Molecular Genetics has partnered with Zhejiang University [in China] in establishing a Joint Centre of Genetics Research and Education, which promotes research collaborations and the development of a joint PhD program.

What are some areas that DFCM can grow by forging partnerships?

We’ve done so many great things in research, particularly with faculty like Drs. Eva Grunfeld, Frank Sullivan, Rick Glazier and Ross Upshur; however, I’d like to see DFCM expand our partnerships in research, locally, nationally and internationally.

We’ve also done so much work around capacity-building in primary care both in Canada and internationally. I’d love to see this grow even more and find new and innovative ways to share our expertise. DFCM really is a world-class family medicine teaching department. We have a responsibility to share this knowledge as much as we can.

During your time as DFCM Chair, partnerships grew considerably. What were your goals for partnerships at DFCM and where do you think partnerships can grow in family medicine?

I really focused a lot on system transformation and our international partnerships while at DFCM. For instance, participating in BRIDGES for better system integration, helping to develop our partnerships in Ethiopia, China and Brazil, and supporting faculty and programs with their own partnerships endeavours were major activities during my time as Chair.

While I think DFCM has become much more effective at developing partnerships, we have additional expertise within DFCM that could and should be shared far more widely. I think, for instance, there are more partnerships to be made within the University itself. But we’re already getting there – DFCM partners with the Joannah and Brian Lawson Centre for Child Nutrition, Choosing Wisely and many more important collaborations.

Training the first generation of emergency medicine physicians in Ethiopia

In 2010, when Dr. Megan Landes began working as co-director of the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) — a partnership with Addis Ababa University to develop Ethiopia’s first-ever emergency medicine residency program — the challenges mainly centred around educating health professionals and others involved in Ethiopia on what emergency medicine really is.

“In the beginning, we were trying to start an emergency medicine program in a country where there was no context for such training,” says Dr. Landes, a DFCM faculty member and emergency physician at the University Health Network. “There were no emergency medicine physicians in the country so a lot of the work that had to be done was around educating the faculty and trainees on what emergency medicine is and its value.”

The program began as a collaboration between Addis Ababa University and the Divisions of Emergency Medicine within the DFCM and the Department of Medicine at the University of Toronto to create and develop the country’s first emergency medicine residency program. Through the partnership, University of Toronto faculty teach and clinically mentor Ethiopian residents three to four times per year for a month at a time. Teaching trips cover a longitudinal, three-year curriculum through didactic teaching sessions, practical seminars and bedside clinical supervision. Each trip to Ethiopia brings three faculty members and one senior postgraduate resident.

The program graduated its first cohort of residents in 2013 and has now graduated a total of 21 emergency medicine specialists. Ultimately, the goal is to build a sustainable critical mass of emergency medicine leaders who will take over the program, including training and curriculum development.

“We are beginning to see how our role in the partnership is evolving as time goes on,” says Dr. Landes. “Our role was initially about graduating residents, but many of those graduates are now taking on positions that contribute to emergency medicine development in hospitals and medical schools across the country. They’re now the leaders and visionaries in emergency medicine in their own country, which is great to see.”

The University of Toronto faculty in Addis Ababa, then, have begun the transition from simply providing curriculum development and resident training, to offering faculty development in areas such as leadership training, building research capacity, advocacy and policy development.

This collaboration is not a one-way relationship:  University of Toronto’s emergency medicine residents have the opportunity to participate in a month-long elective in Addis Ababa three times per year. The residents who participate in the elective are provided with plenty of support through pre-departure orientation sessions before travelling and are supervised by University of Toronto faculty members while training in Ethiopia, thereby mitigating some of the issues residents can face when undertaking international electives. The process for filling these elective spots is highly competitive.

“Our residents receive many benefits from participating in the TAAAC-EM elective, including feeling more engaged in global health. They also find the clinical pathology is really educational and the cultural exposure is really important for them as they grow in their careers,” says Landes. “We find that the residents who did an elective in Ethiopia are now returning as part of our DFCM faculty interested in participating in global health.”

It’s a win-win, then, for all partners involved in a collaboration that only seems to be growing and evolving as emergency medicine becomes more firmly established as a specialty in Ethiopia.

Highlights of the last three years: U of T Medicine inks major agreement in China

This story was initially published in the U of T News on April 21, 2014

Under the agreement, DFCM — the largest family medicine training program in North America — will work with Fudan University’s Department of General Practice to improve the quality of its general practice training. This effort will include an exchange of faculty members between Toronto and Shanghai.

In addition, DFCM will develop a partnership with two community health services centres in Shanghai to assist with delivery and management of primary health care. Both parties agreed to strengthen ties and co-operate in the prevention and control of chronic diseases, with a focus on health management for high-risk populations.

Reducing unnecessary medical testing through Choosing Wisely Canada

Since its creation in 2014, Choosing Wisely Canada (CWC) has begun a vigorous conversation in Canada around unnecessary medical testing. The campaign aims to help clinicians and patients engage in conversations about unnecessary tests, treatments and procedures in order to make smart and effective choices and ensure high-quality care. In a relatively short period, by partnering with many different national, provincial and local health-care organizations, engaging in awareness campaigns and creating useful and informative tools for both physicians and patients, CWC has already raised awareness of the potential dangers and inefficiencies of “unnecessary medicine” across the country.

Dr. Kimberly Wintemute, a DFCM faculty member at North York General Hospital and previous Medical Director of North York Family Health Team (2008 – 2016), is the Primary Care Co-Lead for CWC, along with Dr. Lynn Wilson. Below, Wintemute talks about CWC and how partnerships and academic collaborations are the key to the campaign’s ongoing success.

How did you get involved with CWC?

I read something about it and became immediately excited. I remember saying, “Yes, this is what we need.” I phoned Dr. Wendy Levinson, the campaign Chair, and told her I was interested in the campaign and needed more of its assets for our FHT. In the following months, Wendy realized the campaign needed primary care leadership and engaged Lynn and me.

Who are the audiences for Choosing Wisely Canada?

While patients are an audience of ours and we have materials for patients, it’s not where we spend most of our energy. The campaign is really about inspiring physicians to make better shared decisions with patients around prescribing, tests and procedures. Currently, our energy is going into building awareness of the campaign and creating and disseminating tools that help physicians engage in shared decision-making.

 Why is it so important for family medicine to be involved in CWC?

Family medicine is the entry point for most Canadians into the health-care system. The message that “more is not always better” in health care really needs to begin where most patients are: In their family doctor’s offices.

What are some of the projects DFCM residents, faculty and staff are involved in through Choosing Wisely?

Within DFCM, we have several projects up and running. Right now we’re working on an ARTIC-funded project (Adopting Research to Improve Care) around deprescribing and decreasing unnecessary thyroid testing. It includes five of DFCM’s teaching sites (North York General Hospital, Michael Garron Hospital, Southlake Hospital, Markham Stouffville Hospital and St. Joseph’s Hospital). We’re examining the spread and sustainability of CWC recommendations that apply to family medicine and measuring their effectiveness. We’re just entering year two of our two-year grant and are seeing great results.

Residents and medical students are getting involved, too. For instance, residents at two different sites are doing projects around desprescribing sedative-hypnotic medications in the elderly. That’s a very difficult task for a physician to undertake, so it’s amazing that we have these residents leading the way. There are also two medical students who have created an educational asset for patients around the periodic health exam – what to expect, and what not to expect. They will be piloting their tool under the guidance of our own Dr. Ruby Alvi. Other trainee projects of which I am aware include decreasing unnecessary thyroid testing and decreasing the number of breast cancer survivors who are receiving ongoing care by oncologists.

Suffice it to say, we have many faculty and residents who are not only engaged in Quality Improvement (QI) and research around CWC, but are also creating assets that will be helpful across the country and potentially on an international stage. That’s tremendously exciting.