Clinical preceptorships that nurture virtual care competencies among family medicine residents or physicians in-training remain understudied. Guided by epistemological views of pragmatism and social constructivism, I designed and implemented a three-phase exploratory mixed-methods study to address the following research questions: • How is clinical preceptorship in virtual healthcare settings conceptualized within the field of postgraduate medical education? • What are the gaps in the way clinical preceptorship in virtual healthcare settings is conceptualized in the field of postgraduate medical education? • To what extent do preceptors involve, prepare, and assess family medicine residents in virtual healthcare settings? • How do preceptors assess and provide feedback to family medicine residents in virtual healthcare settings? In phase I, a scoping review identified 24 peer-reviewed articles (published before February 25, 2021) relevant to clinical precepting with postgraduate medical trainees in virtual healthcare settings. In a sequential manner, I then led a one-time online survey (phase II; n = 38) and key informant interviewing (phase III; n = 13) with preceptors of family medicine residents. National data confirmed that clinical precepting in virtual healthcare settings can be characterized by individual factors, preceptor-resident behaviors, and workplace artefacts. Additional insights supported preceptors’ ability to engage family medicine residents in virtual care activities, along with the constraints and strategies to supervise them effectively. Opportunities to assess competency are possible; however, preceptors identified gaps in assessment practices to identify underperformance in the virtual therapeutic frame. A key research deliverable is a thematic framework illustrating the experience of clinical precepting in virtual healthcare settings. Drawing on adaptive expertise, actor-network theory, and praxeology, the final article elucidates how this work contributes to educational solutions and research directions for competency-based family medicine education.

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Indiana University-Purdue University Indianapolis (IUPUI) / Access to healthcare services is important for improving health outcomes, preventing and managing illness, and achieving health equity. The geographic maldistribution of physicians has a negative impact on rural areas compared to urban, particularly as it relates to access to healthcare. Rural hospitals have been closing or converting to another form of healthcare service at an increasing rate, adding another element to the existing complexities in rural access to care. Although a hospital closure in any location may have a considerable impact on the community, the closure of a rural hospital may have disproportionately more substantial implications for the economy and employment, health outcomes, and access to care. The contributing factors preceding rural hospital closures have been studied, but less is known about the full impact of rural hospital closures on the community. There is some evidence of shortages in healthcare providers and services, and therefore communities may employ multiple strategies to mitigate the shortages and provide services, including utilizing telehealth/virtual services. This dissertation proposes to examine the effects of rural hospital closures on the community, healthcare services, access to care, and provide a qualitative assessment of telehealth as a strategy to bridge gaps in provider access. This dissertation includes three studies: 1) a systematic review of the literature to examine the impact of rural hospital closures on the community; 2) an empirical study that utilizes a generalized difference in difference design with county and year fixed effects to estimate the relationship between rural hospital closures and nursing homes; and 3) a qualitative study exploring the perceptions and experiences of the nurses that piloted a virtual care support project, providing insights into crucial elements important to the implementation of similar models and the role of telehealth in bridging healthcare workforce gaps.

Purpose: With the start of the SARS-COV-2 pandemic in March 2020, Canadian primary care practices temporarily shifted from in-person to virtual care. The purpose of this thesis was to understand whether the pandemic impacted the primary care management of older adults with varying levels of frailty and multimorbidity in terms of care modality, volume of encounters, and visits for anxiety/depression. It also aimed to identify which patients comparatively experienced greater reductions in frequencies of routine preventive care and monitoring activities. Methods: A research database from a sub-set of MUSIC family practice for patients ≥ 65 years of age (n=1813) was employed. Patient demographics, clinician-assessed frailty status, encounters, and chronic disease management information were retrieved. Changes from 14 months pre to 14 months since (peri) the pandemic were described and associations between patient characteristics and the extent of changes in outcomes from pre- to peri-pandemic were analyzed using regression models. Results: The mean age was 74 years, with a mean of 2.5 chronic conditions (26% hypertension, 14% diabetes). 2.1% of patients experienced high frailty levels. The mean number of encounters increased peri-pandemic overall (peri: 10.4 (SD 11.1) vs. pre: 7.1 (SD 5.5)) and for anxiety/depression, with most visits becoming virtual. Increasing numbers of overall visits were significantly associated with female sex, increasing frailty level, and having 4+ conditions. While the frequency of routine preventive and monitoring activities related to chronic conditions decreased, the mean values (e.g., lab results) did not considerably change. In the adjusted models, generally older patients, with increasing levels of frailty, and numbers of conditions tended to receive more care, however most associations were not statistically significant. Conclusion: Overall encounters and visits related to anxiety/depression increased peri-pandemic. Despite concerns about pandemic-related care disruptions, common elements of primary care among higher risk older patients were not notably impacted. / Thesis / Master of Health Sciences (MSc) / Many adults ≥65 years of age live with chronic conditions or frailty, requiring ongoing monitoring. Primary care physicians are fundamental in providing this continuous care. With the COVID-19 pandemic, healthcare access was restricted, many doctors switched to temporarily providing virtual care, and there were concerns about patients’ mental health. Questions arose regarding possible gaps in primary care and where efforts should be focused post-pandemic. The objectives of this thesis were 1) to understand how the pandemic impacted the management of this population and the changes in care patterns (modality, encounter numbers overall and for anxiety/depression, and chronic condition management); and 2) identify patient characteristics associated with changes. There was an overall virtual care driven increase in encounters peri-pandemic and for visits relating to anxiety/depression. Frequencies of chronic condition care activities dropped, however older patients and those with increasing levels of frailty and numbers of conditions tended to be better monitored.

Contexte : En raison de la pandémie COVID-19, de nombreux programmes pédiatriques spécialisés en troubles des conduites alimentaires (TCA) ont fourni des soins à distance. L'état actuel de la pratique dans les programmes canadiens demeure toutefois inconnu. Ce mémoire vise donc à décrire les adaptations effectuées dans les programmes pédiatriques spécialisés en TCA au Canada et l'impact de ces adaptations sur l'expérience de prestation de soins. Méthodes : Une méthodologie mixte a été utilisée pour interroger des professionnels de la santé travaillant dans des programmes pédiatriques spécialisés en TCA au Canada à l'aide d'un questionnaire transversale et d'entretiens semi-structurés, entre octobre 2021 et mars 2022. Des statistiques descriptives et une analyse de contenu qualitative one été employés. Résultats : Dix-huit professionnels ont répondu au questionnaire. Six d'entre eux ont participé aux entretiens. La majorité des participants ont fourni des services multidisciplinaires à distance durant la pandémie par vidéoconférence (17/18) ou par téléphone (17/18). Souvent, ces services ont été combinés à des soins en personne. La plupart des participants (16/18) s'attendaient à ce que les soins virtuels soient utilisés dans le futur. L'analyse qualitative du contenu a permis de faire ressortir cinq thèmes décrivant l’expérience personnelle des professionnels de la santé qui fournissaient des soins durant la pandémie : (1) répondre à une demande accrue avec des ressources insuffisantes; (2) s'adapter aux changements dans la prestation des soins dus à la pandémie de COVID-19; (3) faire face à l'incertitude et à l'appréhension; (4) les soins virtuels en tant qu'outil clinique acceptable et utile; et (5) les conditions optimales et les attentes pour l'avenir. La plupart des participants aux entretiens avaient une vision globalement positive des soins virtuels. Conclusions : Tous les participants ont été en mesure de fournir des soins multidisciplinaires virtuels et les ont jugés acceptables en tant qu'outil supplémentaire au traitement standard. Ainsi, les soins hybrides, combinant le traitement en personne et virtuel, peuvent être bien adaptés au traitement des TCA chez les jeunes et contribuer à améliorer l’accès aux soins dans le futur. / Background: As a result of the COVID-19 pandemic, many specialized pediatric eating disorder (ED) programs adapted their services and provided care at a distance. The current state of practice in Canadian programs, however, remains unknown. Thus, this thesis aims to describe the adaptations made in specialized pediatric ED programs in Canada and the impact of these adaptations on health professionals’ experience of providing care. Methods: A mixed methods design was used to survey healthcare professionals working in specialized pediatric ED programs in Canada. Data were collected between October 2021 and March 2022 using a cross‐sectional questionnaire and via semi‐structured interviews. Quantitative data were summarized using descriptive statistics and qualitative data were interpreted using qualitative content analysis. Results: Eighteen healthcare professionals completed the questionnaire, of whom six participated in the semi‐structured interviews. The questionnaire showed that, unlike prior to the pandemic, the majority of participants provided multidisciplinary services at a distance, via videoconferencing (17/18) or telephone (17/18). In many cases, this was combined with in-person care. Most participants (16/18) expected that virtual care would continue to be used after the pandemic. Qualitative content analysis generated five themes describing the personal experiences of the health professionals who were providing care during the COVID-19 pandemic: (1) responding to increased demand with insufficient resources; (2) adapting to changes in care due to the COVID‐19 pandemic; (3) dealing with uncertainty and apprehension; (4) virtual care as an acceptable and useful clinical tool, and (5) optimal conditions and future expectations. Most interview participants had globally positive views of virtual care. Conclusions: All participants were able to provide multidisciplinary care virtually and found it to be acceptable as an additional tool to standard treatment. Thus, hybrid care, combining in-person and virtual treatment, may be well-suited to specialized pediatric ED treatment in Canada in the post-pandemic period. It may be a useful tool for increasing access to care in the future.

With an aging population that suffers from comorbidity, healthcare is facing grand challenges. In order to meet the demand, digitalization is thought to be an opportunity. Digitalization of curative care, such as diagnostics and treatment, have been initiated and is today used and appreciated. Preventative care, on the other hand, has not been included in the digital adaptions to the same extent and there are few scientific studies within the area. Nonetheless, a further proactive care that meets patients and healthcare personnel are of interest to several actors. The Swedish Government has a vision that Sweden, in 2025, will be world leading within eHealth. For that to be possible, digital preventative care have to support and complete the preventative work that is performed today. The present study has investigated the attitude towards Connected Medical Devices for Prevention (CMDfP) within the primary care. By a mixed-methodology including questionnaires, the opinions of 24 health center personnel and 17 patients prescribed with Physical Activity on Prescription (PAP) were collected and analyzed. The results show that health center personnel are willing to prescribe connected eHealth devices for prevention and patients are willing to use the devices prescribed. Additionally, among the respondents there is a belief that CMDfP could facilitate in order to increase the adherence to PAP without any major impact on the personnel's workload. By digitalizing preventative care, it is possible that people will be able to live healthier and therefore not require care to the same extent as today. Reasons to the possible results are that digital tools within curative care have been shown to generate positive outcomes to chronically ill patients that utilize home care. Additionally, studies of preventative care have generated positive outcomes to the health of the population in several countries. It is therefore likely that the combination, digital preventative care, would be rapidly relished. These thoughts align with the positive results on attitudes of this study. Before CMDfP could be prescribed to patients, pilot studies have to be performed and new work routines including reimbursement models, have to be established within healthcare. These are all areas of future work within medical engineering. / Med en åldrande population som lider av samsjuklighet, står hälso- och sjukvården inför stora utmaningar. För att möta behovet är digitalisering en möjlighet. Digitalisering av åtgärdande vård, så som diagnostik och behandling, har redan påbörjats och är idag uppskattat. Preventiv vård har, å andra sidan, inte varit inkluderad i den digitala utvecklingen och därav saknas det vetenskapliga studier inom området. Dock är en mer proaktiv vård av stort intresse för flera aktörer. Sveriges regering har en vision att Sverige, år 2025, ska vara världsledande inom eHälsa. För att detta ska vara möjligt måste digital preventiv vård möta och komplettera det preventiva arbete som bedrivs idag. Denna studie har undersökt attityderna till Uppkopplade Medicinsktekniska Hjälpmedel för Prevention (UMHfP) bland primärvården. Genom en metod som inkluderat enkätundersökningar, inhämtades och analyserades attityden av 24 personer från personalen på vårdcentraler och 17 patienter med Fysisk Aktivitet på Recept (FaR). Resultaten visade att primärvårdspersonal är villiga att förskriva UMHfP och att patienter vill använda de hjälpmedlen som förskrivs. Dessutom har respondenterna tro att UMHfP kan underlätta att förbättra följsamheten till FaR utan att påverka personalens arbetsbörda nämnvärt. Genom att digitalisera den preventiva vården är det troligt att befolkningen kommer få ett hälsosammare leverne och därför inte behöva vård i samma utsträckning som idag. En anledning till detta är att digitala hjälpmedel för åtgärdande vård har visat sig vara positivt för kroniskt sjuka patienter som hemsjukvårdas. Dessutom har studier inom preventiv vård indikerat flera positiva konsekvenser för invånares hälsa världen över. Det är därför troligt att digitala hjälpmedel i kombination med preventivt arbete snabbt kommer bli uppskattat. Dessa spekulationer sammanfaller väl med det positiva resultatet från denna studie. Innan UMHfP kan förskrivas till patienter måste pilotstudier genomföras och nya arbetssätt inklusive betalningsmodeller måste införas i hälso- och sjukvården. Detta är kommande arbeten inom medicinsk teknik.