This study was designed to try to look for the first time in ten years at any gaps in the training of general internists in Canada. Information from the United States indicates that there is a discrepancy between the practice patterns of practising internists and what they perceived their training programs prepared them for [2–6]. There are major differences in the practice of General Internal Medicine between the United States and Canada [7–9]. These include both the nature of practice (primary care in the US versus referred specialty care in Canada) and the length and kind of training. Training in the United States is generally a year shorter and based more heavily in the ambulatory setting. It is therefore important to have Canadian data on which to base the content and structure of Canadian programs.
This study like those in the United States [2, 6, 10–16] demonstrates that graduates of Canadian GIM programs note gaps between preparation and importance for several procedural skills. This is particularly true for several ambulatory based procedures (example ambulatory ECG monitoring). Consideration should be given to having further emphasis on such procedures in GIM training programs. Canadian general internists are perceived to perform many procedural skills in practice. Two studies have looked at the procedural skills performed by Canadian General Internists [17, 18], without solid conclusions as to which procedural skills would be particularly needed by graduates of a General Internal Medicine training program.
Many procedures are performed by very few individuals. We would therefore propose that flexible, individually tailored programs would best fit the needs of individual residents and presumably society. It would be reasonable to expect that all trainees in GIM training programs learn those skills that at least 50 % of respondents utilize at least once per month (ambulatory ECG interpretation, paracentesis, lumbar puncture, ACLS/CPR, cardioversion, mechanical ventilation, articular drainage, endotracheal intubation, hemodynamic monitoring, exercise stress testing, transthoracic pacing). This would be in addition to the eight skills in the Royal College of Physicians and Surgeons of Canada Internal Medicine objectives (central venous catheter insertion; lumbar puncture; peripheral arterial catheter insertion; abdominal paracentesis; endotracheal intubation; thoracentesis; knee joint aspiration; and electrocardiographic interpretation). For other skills an individualized training program for each resident taking into account their eventual needs and where they are likely to practice is proposed versus a long list of required competencies for each resident.
Tailoring of training to the various contexts (example in hospital, academic, outpatients) within which general internists may practice was suggested by the SGIM task force in the United States [19, 20] along with the suggestion that general internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, earning a certificate of added qualification in generalist fields [19, 20]. Although much less has been written about the fit of general internal medicine into the Canadian health care system [7–9] we would propose a similar training pattern for Canadian general internists.
In 1989 Linda Snell undertook a survey of practicing Internists in Canada [1]. There were perceived deficiencies in training in ambulatory care, in the management of complex disorders over time, in management of geriatric patients and those with psychosocial problems. Other areas of perceived deficiency included procedures, especially ICU and endoscopy, teaching skills, continuing self-education skills as well as administration and office management. There was over preparation in other areas. Shamekh and Snell in a survey of graduates of one University found that the current ambulatory care structure in their training program did not satisfy the needs of the graduates [21].
Like these previous studies our data illustrates a gap between importance and preparation for training particularly in the areas of ambulatory care and chronic disease management. There is also a gap perceived for preparation for perioperative care and medical disorders of pregnancy. This is particularly disturbing in that in Canada these have been 'traditionally' felt to be key aspects of GIM practice. Ambulatory care and community general internal medicine are the rotations being pointed out as needing to be strengthened.
In other specialties evidence has shown a gap in training in such non-clinical skills as health service delivery and non-clinical roles [22]. Whether this is true in Canadian GIM programs was suspected by the authors but not documented in the literature. In New Zealand one of these gaps was overcome by developing a national forum for all registrars in several non-clinical skills [22]. Our study shows a dramatic discrepancy between preparation for set-up of an office and importance suggesting that areas of instruction outside the CanMEDs role of medical expert need to be strengthened, perhaps with such a national forum. A recent study looking at paediatric residency programmes in Canada [23] also indicated less than adequate preparation for manager of an office practice.
There are limitations to this study. The response rate is low and was hampered by trying to find individuals in programs that are not registered by the Royal College of Physicians and Surgeons of Canada directly. This made it difficult to find many of the addresses and respondents. As well as these individuals may have been registered in a 4th year program with the intent to eventually go into a subspecialty (approximately 35 %) this information is contaminated by some individuals who went on to become subspecialists. To avoid this we could have surveyed those individuals who are currently practicing GIM in Canada and sought out these individuals either through communities directly or through the Canadian Society of Internal Medicine to which many general internists in Canada belong. Many of the general internists particularly in rural community areas in Canada are not trained in Canada and many come from other countries. As the intent of this study was to look specifically at the discrepancy between preparation and importance for those who have trained in Canadian training programs we chose to identify our respondents this way.
As with many survey studies our results are individual's perceptions only. Individuals may not feel prepared in a topic but may actually able to practice the competency quite well. This data is unknown and is not captured in this study. We do want to take into account the perspectives of those practicing GIM as we develop the objectives for GIM in Canada thus although it is not a gold standard for competence we do believe the perspectives of these respondents is important. As the number of respondents in each year cohort is small we are unable to assess whether more recent graduates feel more confident in areas such as office management which may be emphasized to a greater extent since the introduction of the Royal College of Physicians and Surgeons CanMeds competency framework in 2000.
