Teaching Family-Oriented Patient Care to Family Medicine Residents in Chile

Family-oriented patient care is an approach to involve the patient’s family in clinical care. ¹ This is a cornerstone skill for family physicians, emphasized in most family medicine residency programs.^{2, 3} However, no standardized approach currently exists for teaching these competencies. ² Here we present the Family-Oriented Patient Care (FOPC) course taught at the Pontificia Universidad Catolica de Chile’s (PUC) family medicine residency as an example of teaching these skills in family medicine.

PUC’s family medicine residency is the largest family medicine residency in Chile, with annual cohorts of 20 to 25 residents. The residency has a 3-year program with specializations in child or adult health. Most residents join after several years of general medicine practice. The residency combines clinical practice according to the residents’ specialization during 4 full days per week and a common curriculum for 1 full day per week. This longitudinal curriculum includes training on communication, evidence-based medicine, health systems management, health promotion and prevention, and primary care research, among other contents.

The FOPC course is an 8-week course that is part of the common curriculum for first-year residents (postgraduate year 1 [PGY-1]). Table 1 presents the course using the Template for Intervention Description and Replication. ⁴ The course has been taught since the creation of the family medicine residency in 1993, training more than 540 residents. Over time, its practical component has been strengthened to become an applied rather than theorical course. The definition of “family” has also evolved, now being considered as the closest emotionally significant social group for patients, regardless of kinship, legal status, or residential or geographical location; and course discussions and application have evolved accordingly.

The current version of the course was developed by Diego Garcia-Huidobro and Gabriela Soto, informed by previous versions, personal training and experiences in family counseling in primary care settings, published resources, ^{5-10, 13} and feedback from Maria Victoria Rodriguez, Pamela vonBorries, and Solange Rivera The course employs a flipped-classroom model,¹⁴, ¹⁵ where residents study assigned readings before in-person sessions. Class activities focus on discussing content, applying knowledge to clinical scenarios, and practicing skills with simulated patients and families. During role-plays, residents act as physicians according to their residency specialization (children or adults) and observe the simulations of their resident peers. Practical application is emphasized, and Appendix Table A presents guidelines for family interview and engagement skills taught during the course. These guidelines were developed based on the Calgary-Cambridge guides, ¹⁶ previous studies and frameworks on family interventions strategies and skills for health consultations, ^{5- 10, 13} and the team’s experience.

Because the course has been taught since the inception of the residency, its evaluation has evolved over time. We present a comprehensive post hoc integration of the most recent ratings used at the PUC’s family medicine residency to assess the course and taught skills, including resident-reported outcomes and external evaluations. The PUC’s Institutional Review Board approved the anonymous use of these evaluations.

Four data sources were used to inform the FOPC course evaluation.

1. Postcourse e valuation (n=18 PGY-1 residents , 2019 ). Until 2019, residents assessed their self-efficacy to apply the course contents in their clinical practice using 5-point Likert scales at the end of the course. Ratings ranged from “not competent at all” to “totally competent.”

2. Annual family medicine residency e valuation (n=56 PGY - 1 residents , 2022 – 2023 cohorts ) . Before their annual review, residents rate the perceived relevance and their satisfaction with courses taught in the residency’s common curriculum. Perceived relevance was rated using a 5-point Likert scale ranging from “completely irrelevant” to “very relevant.” Overall satisfaction was rated using a 1–7 scale, commonly used for grading in Chile.

3. Supervisor evaluations (n=67 PGY-1 to PGY-3 residents, 2023). Clinical supervisors annually assess residents’ CanMEDS competencies ¹⁷ [17] using a structured instrument rated using a 5-point Likert scale ranging from “very below expectations” to “excellent.” Under the communicator and health advocate CandMEDS domains,¹⁷ the instrument includes items focused on family engagement. Supervisors based their ratings on integrated direct resident observations, patient precepting, and clinical discussions with the supervised residents.

4. Observed s tructured c linical e xamination (n=46 PGY-1 and PGY - 2 residents , 2023 ) . As part of their evaluation, residents annually complete an Observed Structured Clinical Examination (OSCE) with two or three simulated patients. In these scenarios, family-oriented care competencies are assessed using 3-point scales: complete, partly complete and incomplete.

For all measures, we estimated scale means and standard deviations using STATA version 14.2 (StataCorp).

Table 2 presents the FOPC course’s evaluation. Residents reported high self-efficacy in applying family-oriented care skills and high satisfaction with the course. Supervisors rated residents favorably on family engagement in patient care. However, OSCE assessments showed only partial application of course skills in simulated clinical scenarios.

Here we present a curriculum to teach FOPC, a critical skill for family physicians. ^{1, 2} Despite the recognized importance of this approach, few strategies for teaching family-oriented competencies have been reported. ¹⁸ This course addresses this gap, aiming to equip residents with skills to integrate families into patient care. The course’s perceived relevance and satisfaction underscore its importance for residents. Postcourse evaluations reflect high confidence in applying course contents and skills. Supervisor evaluations suggest skill translation into practice. However, OSCE results indicate that residents struggle to fully implement taught skills in simulated clinical scenarios. Limited application in the OSCE may be attributed to the nature of the OSCE evaluations (which are designed to assess a wide myriad of clinical competences, not just FOPC), time constraints, residents’ focus on medical knowledge and skills, standardized versus real-life variability in which OSCE might not fully replicate real clinical encounters, or lack of learning of FOPC skills. ¹⁹ This gap highlights the need to revisit OSCE clinical cases to strengthen the supervised practice of this approach to patient care, offer greater practice with simulated families, and provide longitudinal integration of this content throughout residency. ²⁰

Despite the comprehensive evaluation of the presented FOPC course, that the course was developed based on the clinical and teaching experience of participating faculty is important to note. Consensus-based approaches to course development could strengthen its curriculum. ²¹ Because few reports of FOPC teaching exist, ¹⁸ comparative studies also are needed to optimize the teaching of these competencies. Next, the anonymous data and changing evaluation strategies did not allow for a longitudinal course evaluation, which is particularly relevant considering that implementation changes over time. Although no major modifications in content, skills, or learning strategies have occurred, over time the course has changed to enhance learning (eg, changes in simulated interviews, course bibliography). For example, during the COVID-19 pandemic, the course was taught completely online. Despite this temporary change in course delivery, the congruence of the different evaluation methods over time support the course’s consistent value. Finally, residents did not complete baseline evaluations prior to the course. In addition, because this course targets PGY-1 residents, no similar control group was used to compare outcomes. We used all available data to describe residents’ perceptions of the course, preceptors’ evaluation of clinical translation, and OSCE results to report residents’ application of FOPC skills. Future evaluations should include baseline assessments to observe skill change and attribute them to the course.

PUC’s family medicine residency experience could serve as a model for teaching FOPC in other residency programs. Standardizing this type of training and assessing its outcomes could contribute to greater consistency in teaching family-oriented patient care competencies—a signature clinical approach of family medicine.