University Of Calgary Postgraduate Medicine

Learner Benchmarks

A Guide for Preceptors: Performance Benchmarks for Family Medicine Residents (*Rotation Based*)

Feedback from our community preceptors has suggested that many physicians would appreciate some guidance in understanding the expectations of family medicine residents at different stages of their two-year residency.

There are widely differing expectations among preceptors of a resident's skills at the beginning of residency. There are also discrepancies in the degree of autonomy granted a resident at all stages of the program, with some preceptors allowing resident freedom to make decisions from the outset while others are more reluctant to grant resident autonomy.

The following pages outline more specifically what family medicine residents should be able to do, and what new skills you can expect them to achieve during the various stages of training. Not all residents will achieve the benchmarks at the same stage of training, but it helps us, as educators, to more accurately gauge the resident's progress.

In addition, information is included about your role/duties as preceptors throughout these stages.

The Direct Observation Policy is incorporated in this document. Please see formal policy document for further details.

A Guide for Preceptors: Performance Benchmarks for Clinical Clerks

The following is meant to provide community preceptors in Family Medicine clerkship with an idea of what clerks should be able to do on coming into clerkship and what new skills you can expect them to achieve during their clerkship rotation.

Skill level, on coming into Family Medicine clerkship, will vary greatly, depending on when, in the 14 months of clerkship, you are seeing a clerk. In general terms, though, the following applies.

At the beginning of Clerkship, a clerk should be able to:

  • Conduct a patient-centred interview, identifying presenting concern(s) and general background information.
  • Perform a basic, systems-based physical exam.
  • Create a differential for the presenting concern(s) and identify basic investigation and management principles for review by preceptor.
  • Be able to access online resources to answer clinical questions.

By the end of Family Medicine Clerkship, a clerk should be able to:

  • Conduct a focused, patient-centered interview, identifying and exploring patient problems and key contextual features which will affect management.
  • Perform focused physical exam.
  • Create a problem list with appropriate differentials and identify likely diagnoses for each of the 29 key clinical presentations.
  • Propose initial disposition, preliminary investigations and management options for review by preceptor.
  • Identify good clinical questions and their answers using appropriate online resources.

First Six Months

  • Resident Responsibilities Open or Close

    Please Note: the following benchmarks apply to Rotation Based Residents ONLY.

    Preceptor Responsibilities

    1. Complete the learning contract with resident. Input from both preceptor and resident is expected.

    2. Establish your expectations re: professional conduct - clinic start time, dress code; expectations re: nursing home visits, in-patient responsibilities etc.

    3. Early: observe complete history and physical until comfortable that resident shows appropriate and consistent skills.

    4. Observe resident doing several pelvic exams.

    5. Thereafter, observe at least a portion of a history or physical at least once per half-day clinic.

    a) Encourage specific goal setting by the resident for these observations

    b) Obtain the residents sense of the success in meeting the goals

    c) Provide detailed feedback 
         - What should they continue to do? 
         - What should they begin or do more of? 
         - What should they stop or do less of?

    d) Develop a specific plan for implementation +/- further specific observation

    6. Remind patients that all resident decisions are reviewed with you.

    7. Encourage residents to explain thinking process in arriving at their DDx ("What else did you consider?").

    8. Ask resident to make a commitment to the most likely diagnosis.

    9. Emphasize SOAP format for record keeping including use of the assessment section to explore their thinking process.

    10. Counter-sign all resident entries.

    11. Encourage resident to read around cases.

    12. Assign reading where necessary (i.e. give a learning prescription).

    13. Stress a professional approach, appropriate boundary setting, and standards for inter-collegial communication.

    14. Ensure formal feedback is given at mid-way point (verbal and/or written if resident is struggling) and end of rotation (verbal and written).

    Resident Abilities

    • Able to complete history and physical exam. History may initially be broad and the development of a focused history is a goal during this first six months.
    • There may be large gaps in knowledge base, especially with respect to common family practice problems.
    • Knowledge of therapeutics may be limited (likely due to lack of formal teaching in problem-based teaching style of most Canadian medical schools).
    • Awareness of psychosocial issues but not always sensitive to them or able to articulate them.
    • Dependant on preceptor for decision-making.

    Responsibilities and Goals of Resident

    • See 6 patients per ½ day clinic.
    • Consult preceptor on each case.
    • Familiarize self with common FM complaints.
    • Learn role of investigations in determining diagnosis and management.
    • Recognize that problem may not be solved in one visit.
    • Become aware of importance of continuity of care.
    • Become aware of importance of family relationships.
    • Improve communication skills; learn to decipher verbal and non-verbal cues.
    • Streamline clinical presentation to include pertinent positives and negatives.
    • Implement the negotiated management plan.  Recognize psychosocial issues which may impact the execution of this plan.
    • Arrange for follow-up of current problem.
    • Update the problem list and medication list at each visit.
    • Ensure formal feedback is given at mid-way point and end of rotation.

6 months to 1 year

  • Resident Responsibilities Open or Close

    Please Note: the following benchmarks apply to Rotation Based Residents ONLY.

    Preceptor Responsibilities

    1. Complete learning contract for 2nd half of year: preceptor and resident input.

    2. Observe a portion of a resident history or physical twice per week using the principles outlined previously.

    3. Discuss each case, but interactions briefer, more focussed.

    4. Fine tune approach to complete medical exam.

    5. Review record keeping with expectation of exemplary records.

    6. Allow resident to increase role in decision-making.

    7. Watch for knowledge gaps, encourage ongoing reading.

    8. Discuss preventative medicine.

    9. Probe for understanding and appreciation for psychosocial aspect of patient's illness experience.

    10. Watch for the over-confident resident who over-estimates ability.

    11. Preceptor should have a good sense of resident's ability.  Concerns should be raised with resident and/or program director.

    Resident Abilities

    • History is crisper; resident uses patient record better; resident is more comfortable with focussed examinations.
    • Better appreciation of the range of problems seen in family practice.
    • Less likely to consider esoteric diagnosis at first contact.
    • Improved ability to demonstrate empathy and active listening.
    • More rational use of investigations.
    • More familiarity with pharmaco-therapeutics.
    • Less intimated than at the beginning of residency.

    Responsibilities and Goals of Resident

    • See 8-10 patients per ½ day clinic.
    • Establish continuity of care with a group of patients.
    • Better understanding of psychosocial issues.
    • Counsel patients on preventative strategies.
    • Still depends on preceptor for exploration of the decision-making process.
    • Incorporate principles and practice of health maintenance into each encounter, where appropriate.
    • Review all lab tests and handle phone calls from their patients.
    • Complete billing procedures for their patients.

     

    Please Note: the following benchmarks apply to Rotation Based Residents ONLY.

    Preceptor Responsibilities

    1. Gradual relinquishing of teacher/learner role and 
    increasing collegial relationship.

    2. Allow increasing autonomy and less supervision as 
    merited.

    3. Allow some decisions regarding patient care even if  preceptor not in full agreement, so long as patient well-being is not compromised.

    4. Maintain regular positive and negative feedback.

    5. Keep time available for resident to discuss cases.

    6. Ongoing regular chart review either case-by-case 
    or at end of day.

    Resident Abilities

    • Sees 10 patients per half day.
    • Comfortable with family medicine setting.
    • Good rapport with patients.
    • Able to see patients alone and make therapeutic decisions in most cases.
    • Able to prioritize patient needs/issues.
    • Cues into "red flag" signs or symptoms.
    • Formulates reasonable management plan.
    • Still tends to over-investigate.
    • Respectful relationships with office staff.
    • Confidently deals with lab results, consultations with specialists, phone calls.
    • Makes appropriate referrals, writes good letters.
    • Growing awareness of community resources.

    Responsibilities and Goals of Resident

    • More aware of gaps in knowledge base; organizes electives to remedy gaps.
    • Organized approach to accessing knowledge.
    • Awareness that on-going learning crucial to long-term competence.
    • Accepts increasing responsibility for patient care.
    • Wants increasing autonomy for patient care.
    • Still reliant on preceptor in many cases for decision-making.

End of 18 months

  • Resident Responsibilities Open or Close

    Please Note: the following benchmarks apply to Rotation Based Residents ONLY.

    Preceptor Responsibilities

    1. Comfortable in allowing resident to manage care of patient in office.

    2. Ensure resident manages time effectively.

    3. Observe resident history or physical exam once per month (i.e. one per every four clinics).

    4. Comfortable with asking resident's advice on difficult cases.

    5. Primary preceptor recommends resident to write CCFP exam.

    Resident Abilities

    • Sees 10-12 patients per half day.
    • Consults preceptor in difficult cases.
    • Good appreciation of limitations.
    • More comfortable in challenging preceptor re: diagnosis and management.
    • Manages challenging interactions with effective communication skills and self-awareness.
    • Has demonstrated some knowledge of family medicine research via an office-based chart audit exercise or research project.
    • Aware of limitations in knowledge, but does not refer for trivial problems.

    Responsibilities and Goals of Resident

    • Preparing for CCFP exam.
    • Identifies deficiencies and seeks skills to rectify.
    • Identifies special interests and seeks further training.
    • Increasingly aware of business aspects of entering practice.
    • Eager to assume responsibility for decision-making with patients.

     

    Please Note: the following benchmarks apply to Rotation Based Residents ONLY.

    Resident Abilities

    • Able to manage office practice, labs, consult letters, on-call, in-patient responsibilities.
    • Sees 12-14 patients per half day.
    • Engages in continuing medical education activities.
    • Most interactions with preceptor are on collegial basis
    • Interacts with patients and colleagues at level of a new locum.
    • You would feel comfortable with resident being a locum for you.