Toward a family medicine capability framework for Canada

Abstract

Objective

To inform the development of a Family Medicine (FM) Professional Capability Framework by examining the competencies and capabilities of high-performing family physicians (FPs).

Design

A mixed-methods explanatory sequential study using a survey and focus groups.

Setting

Ontario.

Participants

Overall, 54 high-performing early-career FPs participated in the survey; and 21 FPs, educators, or leaders participated in the focus groups.

Main outcome measures

To identify the 25 top-ranking competencies and capabilities of high-performing FPs.

Results

The 25 top-ranking attributes of high-performing FPs were predominantly a set of personal, interpersonal, and cognitive capabilities. There was overwhelming consensus among focus group experts on the key capabilities and competencies for successful practice, thus validating the FM Professional Capability Framework. FPs reported not being equipped with specific competencies such as business management and leadership, personal capabilities (tolerating uncertainty and ambiguity, remaining calm under pressure, willingness to persevere when things go awry, and ability to make hard decisions), interpersonal capabilities (understanding how different groups operate in organization and influence situations, ability to communicate effectively and resolve conflicts, how to work in diverse teams), and intellectual capabilities (diagnostic, critical, and creative thinking, and self-reflection).

Conclusion

FPs report that the FM residency training is not sufficiently developing key competencies and capabilities for successful practice. The FM Professional Capability Framework can be used to augment existing physician competency frameworks to drive enhancements in curriculum design, teaching, learning, assessment, and certification. This approach has the potential to foster the development of a robust FP workforce that can effectively respond to, adapt to, and successfully navigate unfamiliar and complex situations, settings, and populations, thereby enhancing physician resilience and the delivery of comprehensive, patient-centred care in an age of uncertainty and accelerating change.

Family physicians (FPs) play a crucial role in delivering continuous, comprehensive, and coordinated services throughout patients’ lifespans.¹ Currently, Canada is facing a primary care crisis—perpetuated by provider shortages, reductions in service volumes and working hours, provider burnout, and narrowing of scopes of practice.^2-14 With a growing population, increased complexity of care, and an expansion of knowledge and technology,^15-19 it is imperative that medical education evolves to prepare physicians to have the capability to adapt to complicated and changing circumstances in this age of acceleration and uncertainty.²⁰

Competency-Based Medical Education (CBME) is an approach to designing, implementing, and assessing medical training programs based on 4 key principles: First, it focuses on outcomes by ensuring that all graduates are competent across essential domains of practice. Second, it emphasizes abilities by organizing curricula around observable competencies that integrate knowledge, skills, and attitudes. Third, it de-emphasizes time-based training, shifting from fixed rotations to progressions based on demonstrated achievement. Finally, CBME promotes learner-centredness by providing milestones and transparent developmental pathways that support individualized learning.²¹ Within this framework, CBME is structured around outcome competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment.²¹

However, critics of CBME argue that this model reduces medicine to discrete, measurable tasks,²² in which assessment is based on “checking boxes.”²³ As such, CBME does not take a holistic approach to physician development, as it neglects the development of professional identity and values, ethical reasoning, and the cultivation of professional judgment, empathy, and adaptability.^22,24-26 These limitations may explain why a national Canadian study found that early-career FPs feel less prepared for practice in virtual care, business management, delivery of comprehensive care, specific services in emergency care hospitals, obstetrics, self-care, and local community engagement.²⁷ Other studies have demonstrated challenges with coping with uncertainty,²⁸ psychosocial and cultural issues,²⁹ and professional issues.^29,30

Preparedness for practice is conceptualized as an interplay of dynamic constructs, including competence, self-confidence, capability, and adaptability.³¹ In addition to competence (ie, a demonstrable ability to deliver skills and knowledge in predictable situations), it requires practitioners to be capable of adapting to and navigating complex, uncertain, and changing circumstances,^32-37 and undertaking lifelong learning. The importance of having the capability to manage the unexpected became evident during the COVID-19 pandemic, when physicians faced complex dilemmas, including patient mistrust and equity issues.

Given the constantly changing context of family medicine (FM), educators will need to continually update medical education to ensure that graduates emerge with both the capabilities and competencies necessary to confidently adapt to the unexpected and successfully navigate an uncertain future. Although the term capability is not commonly used in FM education, the underlying ideas overlap with concepts such as adaptive expertise and preparedness for practice, both of which have been recognized as outcomes of FM training.³⁸ Our study builds on these foundations by framing capability as a construct that explicitly integrates dimensions of adaptive expertise with personal, interpersonal, and cognitive attributes. By identifying the key capabilities and competencies of high-performing, early-career FPs, this study develops the first, to the best of our knowledge, validated FM Professional Capability Framework.

METHODS

Study design

We used a mixed-methods explanatory sequential study design.^39,40 The first phase involved a survey that collected quantitative and qualitative data. The second phase included focus groups. The study was theoretically informed by the Professional Capability Framework,³⁹ which consists of personal capabilities (self-awareness, decisiveness, commitment), interpersonal capabilities (influencing, empathizing), cognitive capabilities (diagnosis, strategy, flexibility, responsiveness), and competency domains (role specific, generic).³⁹

In this study, we distinguish between competencies and capabilities. Competencies refer to integrated knowledge, skills, and professional behaviour required to successfully perform the duties of a particular role to an agreed standard within relatively predictable conditions.⁴¹ Capabilities go beyond competencies, encompassing the personal, interpersonal, and cognitive capacities that enable physicians to adapt, innovate, and respond effectively to uncertainty and complexity in practice.⁴¹

The Good Reporting of a Mixed Methods Study checklist is used for reporting.⁴² This study is approved by the University of Toronto Health Sciences Research Ethics Board (#41799).

Participant recruitment

We used purposive and convenience sampling⁴³ to recruit participants from Ontario. Survey participants included high-performing, early-career FPs who were 1 to 5 years into practice. A high-performing FM graduate is a graduate who is competent and able to confidently transition and adapt to the independent practice of comprehensive FM, in which adaptation involves the ability to effectively navigate diverse and unfamiliar situations, settings, and patient populations. High-performing FPs were identified through a nomination process with university educators, early-career FPs, and experienced leaders. Selection was based on established criteria in previously published studies of different disciplines.^33-37 Nominators were asked to identify early-career FPs who, during training or their first years in practice, consistently demonstrated timely and reliable completion of clinical work to the required standard; high levels of patient satisfaction; strong co-worker satisfaction; high motivation and eagerness to learn and advance skills; proactive behaviour such as initiating collaboration or reviewing complex cases; strong communication and liaison skills; effective organization and time management; and high levels of competency and professionalism. These criteria reflect prior definitions of high-performing graduates across disciplines.³⁹ We also validated these criteria with participants to confirm their relevance. Focus group participants included university-based educators, practising FPs, and experienced leaders from professional organizations.

Participants for cognitive testing, nominators of high-performing FPs, and focus group participants were recruited using purposive and convenience sampling methods based on their experience and expertise.⁴³ Participants were identified through the research team, departmental websites, communications through professional organizations or committees, and snowballing techniques.⁴⁴ Recruitment of nominators and nominees took place between May 2022 and June 2024. Focus groups were held between January and March 2025.

Data collection

A survey instrument with very strong validity evidence was employed.³⁶ The questionnaire was supplemented with questions on demographic characteristics and professional practice using existing instruments (ie, Statistics Canada, University of Toronto Student Equity Census, and the Family Medicine Longitudinal Survey). The research team revised the terminology and reworded certain items. An open-ended question was added: “Are there other factors that have contributed to your success? If so, please explain.”

Cognitive testing was conducted to validate the instrument through interviews with early-career FM graduates from Ontario.⁴⁵ Three male and 3 female FPs consented to participate and provided feedback on comprehension and interpretation of questions, survey content, timing, and ease of use. A $25 gift card was provided to each participant.

Participants confirmed that all the survey items were relevant to FM. Minor revisions were made to sections about demographic characteristics, professional practice, terminology, or the addition of examples. Three questions were added on third-year enhanced skills, locums, and academic institutions. One item was added: “Understanding the local context to deliver care to patients.” The final FM Professional Capability questionnaire had 6 sections with 64 items (Supplemental Material 1, available from CFPlus^*).

Participants rated the importance of personal, interpersonal, and cognitive or intellectual capabilities, and generic and role-specific skills and knowledge for successful professional practice. Participants were asked to rate the “importance of an attribute for successful performance in current practice” and the “extent to which there should be further development in the family medicine residency program.” Open-ended questions identified gaps in competencies and capabilities, situations when professional capability was most heavily tested, factors contributing to success, and opportunities for improvement. Participants were sent the questionnaire using the research electronic data capture (REDCap) software.⁴⁶

Virtual focus groups were conducted using Zoom teleconferencing software to test the veracity and implications of the results. The principal investigator (PI; M.A.) presented findings and neutral facilitators led 90-minute sessions. Participants were asked to confirm the validity of the results and provide feedback on gaps in the FM Capability Framework and educational strategies (Supplemental Material 2, available from CFPlus^*). The focus group sessions were audiorecorded and transcribed. The PI and research assistant (RA) took field notes during and immediately after each focus group to capture contextual observations and reflections. Data from these sessions were saved. Transcripts were reviewed for accuracy. Each participant received a $100 gift card.

Analysis

Descriptive analysis of the questionnaire data was performed using SPSS, version 28.⁴⁷ Previous methodology was used to determine the mean rating and rank for each survey item.^33-37 To ensure the robustness of the analysis, we tested various methods for operationalizing outcomes related to the importance and focus of FM residency programs using the Cohen d effect size (for paired tests) and the McNemar test (using dichotomous variables to evaluate variations in responses). The results were compared with the existing methodology for mean and rank. The analysis confirmed that, while the exact ranks varied slightly between methods, the overall inferences drawn remained consistent across the different metrics.

For the qualitative survey data, a content analysis⁴⁸ was conducted on open-ended data to explain participant ratings and improvements to training. We employed a multilevel approach to coding (ie, analysis triangulation), which included open, inductive, deductive, and quantitative techniques, to gain a comprehensive understanding of participants’ responses to each question.^49-54

Focus group data were analyzed using Braun and Clarke’s 6 steps for thematic analysis.⁵⁵ Data were open-coded by an RA and reviewed by the PI. Themes emerged related to the degree of consensus on the FM Capability Framework and educational strategies for recruitment, learning, teaching, and assessment.

Survey and focus group data were triangulated to provide a more detailed analysis.⁵⁶ Through team meetings and discussions, meaningful interpretations were generated.

RESULTS

Respondents

The survey was completed by 45 early-career FPs. Four nominees declined to participate. Approximately 67% were women. Participants were from predominantly white and Asian backgrounds and had an average age of 32.5 years. Overall, 60% reported being in an independent practice, 76% delivered some form of comprehensive care, and 70% worked in urban-suburban areas. Twenty-one family medicine educators (24%), leaders (38%), or FPs (38%) participated in focus groups with almost equal representation of men (48%) and women (52%). One person declined to participate (Supplementary Materials 3 and 4, available from CFPlus^*).

Survey results

Top-ranking personal capabilities. Table 1 identifies the 6 personal capabilities ranked highest by respondents and the extent to which they were addressed in FM training. For example, “being willing to face and learn from errors and listen openly to feedback” was ranked number 1 in importance for effective practice and number 1 related to focus on FM residency training. Personal capabilities that ranked high on the importance for practice but ranked lower on focus during training included “ability to remain calm under pressure or when things go wrong” (ranks 3 and 7), “a willingness to persevere when things are not working out as anticipated” (ranks 4 and 8), and “the ability to make a hard decision” (ranks 4 and 6).

Table 1.

Personal capabilities

ITEM*	IMPORTANCE FOR SUCCESSFUL PRACTICE		RESIDENCY FOCUS		PAIRED DIFFERENCES—COHEN d EFFECT SIZE†
	MEAN RATING	RANK	MEAN RATING	RANK
Being willing to face and learn from my errors and listen openly to feedback	4.64	1	4.16	1	0.588
Understanding my personal strengths and limitations	4.63	2	3.76	4	0.817
Being able to remain calm under pressure or when things go wrong	4.56	3	3.60	7	0.812
Wanting to produce as good a job as possible	4.56	3	3.95	2	0.532
A willingness to persevere when things are not working out as anticipated	4.44	4	3.58	8	0.795
Having the ability to make a hard decision	4.44	4	3.65	6	0.819
Being willing to take responsibility for projects, including how they turn out	4.29	5	3.70	5	0.471
Being able to keep work in perspective	4.26	6	2.93	11	1.133
Having the ability to defer judgment when interacting with and navigating conflicts with colleagues	4.23	7	3.19	10	0.854
Being confident to take calculated risks and take on new projects	4.16	8	3.51	9	0.726
A willingness to pitch in and undertake menial tasks when needed	4.05	9	3.84	3	0.194

^*Missing data represent the percentage of participants who did not respond to items: 4.4% to 6.7%.

^†Effect sizes: small, d=0.2; medium, d=0.5; large, d≥0.8.

A key theme that emerged from participant responses to open-ended questions was the need for FPs to “handle complexity, ambiguity, and uncertainty effectively” (participant 7) (Table 2).

Table 2.

Five capabilities and competencies from qualitative data

CAPABILITIES AND COMPETENCIES	QUOTATION
Tolerating complexity, ambiguity, and uncertainty (PC)	“As a long-time teacher of family medicine, I’ve been wondering what’s wrong. For the past several years, I’ve watched graduates go into practice and put up a ton of barriers to restrict volumes, restrict how much time they’re going to spend, and really their own personal lives. It’s like this firm boundary. And I’ve wondered, how did that happen? And I love your finding of the tolerating ambiguity and uncertainty. And I’m wondering if drilling down on that might be helpful because I see a cognitive rigidity setting in. And I’m just, I’ve watched this cognitive rigidity setting in fairly early in residency. I don’t see it so much in clerkship, but I see it starting in sort of mid first-year residency of like the brakes go on. Oh my God, what are we getting into? And then this cognitive rigidity sort of sets in, and it’s almost like I’m not going to deal with that uncertainty or the ambiguity” (focus group 2)
Creative and critical thinking and self-reflection (CC)	“I find that being able to take a step back to reassess the entire picture of an ongoing situation (whether it is clinical or nonclinical) and reprioritizing/reorganizing has been key in preventing burnout” (survey, participant 64)
Business and practice management (GSK)	“A lot of times there’s a fair bit of idealism that’s involved in the residency programs and I do respect that. I truly do respect that. And there’s not a lot of, in fact, there’s zero talk done on how do you bill appropriately? How do you do a performance appraisal on your staff? How do you find the right people that will, or the right companies that will give you the best deals on supplies that you need? How do you negotiate and lease? And yet these are all skills that a comprehensive care family physician will need” (focus group 1)
Leadership in practice, policy, and other settings (GSK)	“We need to be teaching the importance of leadership and what family doctors can do and how generalism makes that actually an ideal operation for you” (focus group 1)

CC—cognitive (intellectual) capabilities, GSK—generic skills and knowledge, PC—personal capabilities.

Interpersonal capabilities. Table 3 identifies the extent to which the 5 interpersonal capabilities ranked highest by respondents were addressed in training. Developing the capability to “understand how the different groups that make up my organization operate and how much influence they have in different situations” was ranked in the top 5 interpersonal capabilities, but had a much lower ranking on focus during training (ranks 4 and 7). Items with an importance rating of more than 4 for successful practice but rating less than 3 on residency focus included “being able to give constructive feedback to work colleagues and others without engaging in personal blame” and “being able to motivate others to achieve great things.”

Table 3.

Interpersonal abilities

ITEM*	IMPORTANCE FOR SUCCESSFUL PRACTICE		RESIDENCY FOCUS		PAIRED DIFFERENCES—COHEN d EFFECT SIZE†
	MEAN RATING	RANK	MEAN RATING	RANK
The ability to empathize with and work productively with people from a wide range of backgrounds	4.78	1	4.00	1	0.764
A willingness to listen to different points of view before coming to a decision	4.57	2	3.67	3	0.806
Being able to develop and use networks of colleagues to help me solve key workplace problems	4.43	3	3.40	5	0.778
Understanding how the different groups that make up my organization operate and how much influence they have in different situations	4.26	4	2.83	7	1.076
Being able to work with more experienced or expert staff without being intimidated	4.20	5	3.69	2	0.362
Being able to develop and contribute positively to team-based projects	4.13	6	3.63	4	0.388
Being able to give constructive feedback to work colleagues and others without engaging in personal blame	4.07	7	2.90	6	0.823
Being able to motivate others to achieve great things	4.07	7	2.90	6	0.941

^*Missing data: 6.7%.

^†Effect sizes: small, d=0.2; medium, d=0.5; large, d≥0.8.

Participants’ narratives aligned with the quantitative data. However, participants noted they were not sufficiently “taught how to deal or give feedback to senior physicians who are rude or judgmental on the telephone” and they were not “… taught to ask as many questions as we can and ask for help” (participant 34) (16 out of 31 participants, 52%).

Cognitive (intellectual) capabilities. Table 4 identifies the extent to which the top 5 cognitive capabilities identified by respondents were addressed in training. “Being able to identify from a mass of detail the core issue in any situation” had the highest ranking on importance for practice, but had a much lower rank for focus in training (ranks 1 and 5).

Table 4.

Intellectual (cognitive) abilities

ITEM*	IMPORTANCE FOR SUCCESSFUL PRACTICE		RESIDENCY FOCUS		PAIRED DIFFERENCES—COHEN d EFFECT SIZE†
	MEAN RATING	RANK	MEAN RATING	RANK
Being able to identify from a mass of detail the core issue in any situation	4.71	1	3.59	5	1.065
Being able to readjust a plan of action in the light of what happens as it is implemented	4.68	2	3.68	3	1.085
Being able to diagnose what is really causing a problem and then to test this out in action	4.66	3	3.71	2	1.033
An ability to recognize patterns in a complex situation	4.65	4	3.73	1	1.041
Being able to set and justify priorities	4.63	5	3.66	4	1.115
The ability to use previous experience to figure out what is going on when a current situation takes an unexpected turn	4.49	6	3.59	5	0.885
An ability to trace out and assess the consequences of alternative courses of action and, from this, pick the one most suitable	4.46	7	3.73	1	0.771
Being able to see how apparently unconnected activities are linked and make up an overall picture	4.43	8	3.46	6	1.131
Knowing that there is never a fixed set of steps for solving workplace problems or carrying out a project	4.12	9	3.24	7	0.767

^*Missing data: 8.9%.

^†Effect sizes: small, d=0.2; medium, d=0.5; large, d≥0.8.

Some participants highlighted “critical and creative thinking” as important for reassessing situations and preventing burnout (4 out of 29 participants, 14%), and “self-reflection” to comprehend their thinking and problem-solving processes, promoting learning and independence (3 out of 29 participants, 10%) (Table 2).

Key competencies (generic and role-specific skills and knowledge). Table 5 identifies the extent to which the 5 competencies surveyed ranked highest and were addressed in training. Those competencies had an importance rating for successful practice greater than 4, but a residency focus rating less than 3 (“understanding the role of risk management and litigation in current professional work” and “understanding how organizations like mine currently operate”).

Table 5.

Generic and professional specific skills or knowledge

ITEM*	IMPORTANCE FOR SUCCESSFUL PRACTICE		RESIDENCY FOCUS		PAIRED DIFFERENCES—COHEN d EFFECT SIZE†
	MEAN RATING	RANK	MEAN RATING	RANK
Understanding the local context to deliver care to patients (GSK)	4.66	2	3.32	4	1.361
Being able to use technology effectively to communicate and perform key work functions (GSK)	4.46	3	3.39	3	0.746
Having a high level of current technical expertise relevant to my work area (PSK)	4.40	4	3.85	1	0.423
Being able to manage my own ongoing professional learning and development (GSK)	4.34	5	3.39	3	0.819
Understanding the role of risk management and litigation in current professional work (PSK)	4.07	6	2.83	6	0.872
Understanding how organizations like mine currently operate (PSK)	4.07	6	2.41	8	1.226
An ability to help others learn in the workplace (GSK)	3.98	7	3.13	5	0.690
Knowing how to manage projects into successful implementation (GSK)	3.76	8	2.83	6	0.655
Being able to make effective presentations to patients and colleagues (GSK)	3.56	9	3.55	2	−0.016

GSK—generic skills and knowledge, PSK—professional skills and knowledge.

^*Missing data: 11% to 13%.

^†Effect sizes: small, d=0.2; medium, d=0.5; large, d≥0.8.

Participants indicated the need for greater focus on business practices and risk management (3 out of 33 participants, 9%) and leadership in practice, policy, and other settings (7 out of 33 participants, 21%) (Table 2).

Focus groups results

In all focus groups, there was overwhelming consensus on the competencies and capabilities identified for the FM Capability Framework and areas of improvement (Supplementary Material 5, available from CFPlus^*). One participant stated:

Just to say that from my perspective, these findings from the survey and from the interview certainly resonate with me…. I also like to see that the competencies and capabilities are represented with overlapping circles because I certainly see that these are very much interrelated, interconnected. (Focus group 1, professional associations and colleges)

Top 25 capabilities for successful family practice. In Tables 2 and 6, the top 25 capabilities and competencies for effective practice are identified and confirmed by experts. In Table 6, the top 20 are listed, with 5 items receiving the same rating. While “being able to organize my work and manage time effectively” ranked as the most important competency, most attributes for effective practice were capabilities. A noteworthy finding is the balance between cognitive capabilities (7 items) and a range of key personal and interpersonal capabilities (13 items) that are often overlooked in higher education learning and assessment. Table 2 presents 5 capabilities and competencies based on qualitative survey data.

Table 6.

Top 20 capabilities and competencies ranked highest on importance for successful family practice: In rank order, highest first.

ITEM (QUANTITATIVE SURVEY)	IMPORTANCE FOR SUCCESSFUL PRACTICE (1—LOW TO 5—HIGH)
	MEAN RATING	RANK
Being able to organize my work and manage time effectively (GSK)	4.79	1
The ability to empathize with and work productively with people from a wide range of backgrounds (IC)	4.78	2
Being able to identify from a mass of detail the core issue in any situation (CC)	4.71	3
Being able to readjust a plan of action in the light of what happens as it is implemented (CC)	4.68	4
Being able to diagnose what is really causing a problem and then to test this out in action (CC)	4.66	5
Understanding the local context to deliver care to patients (GSK)	4.66	5
An ability to recognize patterns in a complex situation (CC)	4.65	6
Being willing to face and learn from my errors and listen openly to feedback (PC)	4.64	7
Understanding my personal strengths and limitations (PC)	4.63	8
Being able to set and justify priorities (CC)	4.63	8
A willingness to listen to different points of view before coming to a decision (IC)	4.57	9
Being able to remain calm under pressure or when things go wrong (PC)	4.56	10
Wanting to produce as good a job as possible (PC)	4.56	10
The ability to use previous experience to figure out what is going on when a current situation takes an unexpected turn (CC)	4.49	11
Being able to use technology effectively to communicate and perform key work functions (GSK)	4.46	12
A willingness to persevere when things are not working out as anticipated (PC)	4.44	13
Having the ability to make a hard decision (PC)	4.44	14
Being able to develop and use networks of colleagues to help me solve key workplace problems (IC)	4.43	15
Being able to see how apparently unconnected activities are linked and make up an overall picture (CC)	4.43	15
Having a high level of current technical expertise relevant to my work area (GSK)	4.40	16
Being willing to take responsibility for projects, including how they turn out (PC)	4.29	17
Being able to keep work in perspective (PC)	4.26	18
Understanding how the different groups that make up my organization operate and how much influence they have in different situations (IC)	4.26	18
Having the ability to defer judgment when interacting with and navigating conflicts with colleagues (PC)	4.23	19
Being able to work with more experienced or expert staff without being intimidated and being able to ask questions and for help, provide feedback, and manage conflicts (IC)	4.20	20

CC—cognitive (intellectual) capabilities, GSK—generic skills and knowledge, IC—interpersonal abilities, PC—personal capabilities.

DISCUSSION

To our knowledge, this study is the first to identify the capabilities and competencies of high-performing early-career FPs. It shows that possessing a set of key competencies is necessary but not sufficient for effective early practice as an FP, and it confirms that FPs feel most challenged when the unexpected happens. It is then that the top-ranked capabilities and competencies identified by respondents become important.

These results align with findings from similar studies in other professions (nursing, medical radiology), which show that emotional intelligence—personal and interpersonal capabilities, in combination with contingent, diagnostic thinking—is crucial for a high-performing health workforce.^33-37 Previous research shows the most effective practitioners are those who can read not only the technical aspects of the situation but also the unique individual human, personal, interpersonal, and cultural aspects of each new encounter; from this “problem formation” they can match the most relevant response to this reading.⁵⁷ This requires high levels of personal and interpersonal capability, combined with a contingent and diagnostic intelligence.⁵⁷

This study also illustrates that high-performing early-career FPs in our Ontario sample do not feel that the current CBME FM training program is equipping them with the right combination of competencies and personal, interpersonal, and cognitive capabilities needed for successful practice. Consistent with other studies, FPs report they lack competencies in business management.²⁷ In this study, FPs reported not being equipped with leadership skills, personal capabilities (eg, tolerating ambiguity and uncertainty, the ability to remain calm under pressure, the willingness to persevere when things go awry, and the ability to make hard decisions). Interpersonal capabilities included understanding how different groups operate within an organization and influence situations, as well as being able to communicate effectively and resolve conflicts with senior physicians while working productively with diverse teams. Intellectual capabilities included diagnostic, critical, and creative thinking, as well as self-reflection.

The findings of this study underscore the importance of incorporating both the competencies and the top-ranking capabilities identified in this study into physician frameworks and standards. Although the College of Family Physicians of Canada has produced a residency training profile to emphasize preparedness for practice, adaptive expertise, nonclinical domains (eg, practice management and leadership), and essential skills (eg, clinical reasoning and some cognitive capabilities),⁵⁸ more work is needed to integrate the personal, interpersonal, and cognitive capabilities identified in our FM Capability Framework. Furthermore, key capabilities should be embedded in program outcomes and assessed throughout training and certification to ensure that learning is purposeful and aligned with the abilities required in practice. An Australian study demonstrated that capability frameworks can be used to align capabilities with Entrustable Professional Activities outcomes during assessments.⁵⁹ Furthermore, access to performance standards and assessment data by learners can facilitate self-directed learning.⁵⁹ A similar approach could be used with the adoption of our FM Capability Framework in Canada.

Limitations

Although we recruited a diverse sample of early-career FPs in terms of gender, ethnicity, and practice setting, most participants were graduates of 2 Ontario-based family medicine residency programs (University of Toronto and McMaster University in Hamilton) and were practising within a single province. Additionally, most participants were practising in urban or suburban settings. Furthermore, the learning experiences of residents may vary considerably across programs and contexts (eg, what constitutes a rural placement in Ontario may differ substantially from one in northern British Columbia). These factors limit the generalizability of our findings, which should therefore be understood as reflecting the perspectives of a relatively small group of early-career, high-performing FPs trained primarily in urban-based residency programs. Although our results were validated by senior experts with extensive experience or expertise in FM (educators, practising FPs, and FP leaders), our conclusions should be interpreted as preliminary and hypothesis-generating, offering insights into potential capability gaps that require validation in broader, more geographically and contextually diverse samples across Canada.

Conclusion

This study developed an FM Professional Capability Framework grounded in the perspectives of high-performing, early-career FPs. The findings highlight capability gaps that participants and experts perceived as not being sufficiently addressed in FM training programs. Through further testing and validation on a national level, the framework offers foundational knowledge that medical educators can use to enhance physician competency frameworks to drive enhancements in curriculum design, teaching, learning, assessment and certification. Together, this approach has the potential to foster the development of a robust and resilient Canadian FP workforce that can effectively respond to, adapt to, and successfully navigate unfamiliar and complex situations, settings, and populations in an age of accelerating change.