Department of Family Medicine (Grierson, Allice, Baker, Farag, Guscott, Howard, Mountjoy, Siu, Tong, Vanstone) and McMaster Education Research, Innovation and Theory Program (Grierson, Vanstone), Faculty of Health Sciences, McMaster University, Hamilton, Ont.
CMAJ Open. 2021 Nov 9;9(4):E966-E972. doi: 10.9778/cmajo.20200278. Print 2021 Oct-Dec.
In 2015, the College of Family Physicians of Canada (CFPC) expanded its Certificates of Added Competence (CAC) program to include enhanced-skill certification in Care of Elderly, Family Practice Anesthesia, Palliative Care, and Sports and Exercise Medicine. We aimed to describe the impact of these 4 CACs on the provision of comprehensive care in Canada, while also identifying the factors of influence that foster these impacts.
Between September 2018 and June 2019, we conducted qualitative case studies of 6 family medicine practices across Canada, sampled to represent geographic, population and practice arrangement diversity. We developed a framework of relevant factors and their relations to CAC-mediated comprehensive care delivery. We took an exploratory approach to the first 4 case studies, guided by theoretical propositions based on a literature review, and the CFPC's 4 principles of family medicine and goals for practice. The emerging theory was confirmed and adapted through the final 2 explanatory case studies. Data were obtained through semistructured qualitative interviews with enhanced-skill and generalist physicians, specialists, trainees and administrators associated with these cases. We performed a descriptive content analysis, within and across cases.
Interviews with 48 participants showed considerable variation in the way CACs are operationalized related to the specific domain of care, the community, relationships among practitioners, motivations of the practitioner and needs of the patient population. The presence of CAC holders in communities expands the scope of available services, reduces the need for patients to travel and encourages continuity of care; however, comprehensive care may be negatively affected when CAC holders develop enhanced-skill practices according to clinical interests rather than community needs. Factors associated with collaborative care models, practice requirements, remuneration structure, community culture and individual aspirations interact to reinforce or undermine the effectiveness of enhanced-skill practices.
Holders of CACs have a positive impact when they work in collaborative models that align with the needs of communities and that support local generalist family physicians. Health care policies should incentivize CAC activities that contribute to planned care delivery at the practice and community levels.
2015 年，加拿大家庭医生学院（CFPC）扩大了其证书附加能力（CAC）计划，包括在老年护理、家庭实践麻醉、姑息治疗和运动与锻炼医学方面的高级技能认证。我们旨在描述这 4 个 CAC 对加拿大全面护理的影响，同时确定促进这些影响的因素。
2018 年 9 月至 2019 年 6 月，我们对加拿大 6 家家庭医学实践进行了定性案例研究，抽样代表地理、人口和实践安排的多样性。我们制定了一个相关因素的框架及其与 CAC 介导的全面护理提供的关系。我们采用探索性方法对前 4 个案例研究进行了研究，这些研究以理论命题为指导，这些命题基于文献综述和 CFPC 的家庭医学 4 项原则和实践目标。通过最后 2 个解释性案例研究，对新兴理论进行了确认和调整。通过与这些案例相关的增强技能和全科医生、专家、学员和管理人员的半结构化定性访谈获得了数据。我们在案例内和案例间进行了描述性内容分析。
对 48 名参与者的访谈显示，CAC 的运作方式在与特定护理领域、社区、从业者之间的关系、从业者的动机和患者人群的需求有关方面存在很大差异。CAC 持有者在社区中的存在扩大了可用服务的范围，减少了患者的旅行需求，并鼓励了护理的连续性；然而，当 CAC 持有者根据临床兴趣而不是社区需求发展高级技能实践时，全面护理可能会受到负面影响。与协作护理模式、实践要求、薪酬结构、社区文化和个人愿望相关的因素相互作用，加强或破坏高级技能实践的有效性。
当 CAC 持有者在与社区需求保持一致并支持当地全科家庭医生的协作模式中工作时，他们会产生积极的影响。医疗保健政策应激励 CAC 活动，这些活动有助于在实践和社区层面上进行计划护理。
