Family medicine, or general practice as described in some countries, by definition, requires a wide, comprehensive range of medical knowledge and the ability to perform diverse clinical procedures. As such, even with the 2005 Korean Academy of Family Medicine (KAFM) residency curriculum under implementation, individual family medicine residency training programs vary widely. In part, this may have to do with the 2005 curriculum being too vast and inclusive. To ensure the quality of nextgeneration family physicians, especially with the new labor laws restricting resident hours to less than 80 hours a week, it is becoming increasingly important to define “essential” or “core” topics and procedures.

Lists of core topics or procedural skills for family medicine residency training programs have been created in several countries by varying methods with diverse outcomes [1-6]. In the case of procedural skills, for instance, in Canada, an initial survey of all residency program directors of family medicine produced 24 lists with the number of skills varying from 10 to 75 [7]. The currently used versions of the lists of priority topics and core procedures are much more comprehensive and will be described later. The United States also initially surveyed all program directors and obtained 63 lists of procedures with varying numbers of skills (3–117) [8]. Currently, two lists of procedural skills (required and advanced) are in circulation, and the Residency Curriculum Resources Project is under progress for the selection of topics [9,10]. The Royal College of General Practitioners also had a list of mandatory procedural skills, although recent changes discarded the specific list and now it requires five mandatory exams with others that are not specified [11].

The KAFM, through the Section of the Residency Training Committee, commissioned the Working Group in 2018. This paper describes the process followed by the Working Group for developing a refined list of topics and procedures specifically for training family medicine doctors in Korea.

This study was conducted using three Internet surveys. The first and second surveys utilized Google Forms and were sent to all board-certified family physicians in the KAFM e-mail database. The third survey was sent to board members of the KAFM via conventional e-mail correspondence. This study was approved by the Institutional Review Board of Severance Hospital (approval no., 4-2020-0969). Informed consent was waived.

Regarding response rates, 256 physicians out of 6,588 responded to the first survey (3.89% response rate) and 209 out of 6,669 to the second survey (3.13% response rate). (Updates to the e-mail database of KAFM explain the number discrepancy.) All 32 board members responded to the third survey. The baseline characteristics of the participants in the first and second surveys are shown in Table 1.

A total of 153 topics and 84 procedures were identified in the first and second surveys. Three procedures were deleted after the third survey; two due to minimal agreement (endometrial aspiration biopsy and artificial rupture of membranes) and one due to possible redundancy, resulting in a final total of 81. The majority of topics were observed to be both considered essential and utilized in practice, with the exception of 19 topics that were thought needed but not personally used (advanced cardiac life support, croup, domestic violence, immigrant health, infertility, newborns, poisoning, rape/sexual assault, schizophrenia, seizures, suicide, care of the surgical patient, homecare medicine, current issues in medicine, lacrimal disorder, retinal disorder, glaucoma, cataract, and manual therapy). In contrast, less than half of the procedures (n=35) were evaluated as both performed and needed.

We categorized the topics and procedures into three groups based on responses to the e-mail surveys: “mandatory,” “recommended,” and “optional.” A total of 112 mandatory topics were defined by the response percentile of above either 70% for “used” or 80% for “need,” and minimum requirement of achievement was set at 90%. The minimum achievement requirements for the 38 recommended topics (40%–70% use or 50%–80% need) and three optional topics (30%–40% use or 40%–50% need) were set at 50% and 30%, respectively (Table 2).

The 27 mandatory procedures were defined by the response percentile of above either 60% for “used” or 80% for “need,” and minimum requirement of achievement was set at 80%. The minimum achievement requirements for the 33 recommended procedures (40%–60% use or 60%–80% need) and 21 optional procedures (20%–40% use or 30%–60% need) were set at 60% and 30%, respectively (Table 3).

It comes as no surprise that early attempts at defining “essential” or “core” lists of topics and procedures produced widely varying results domestically, as have the final versions differed largely between countries. In the aforementioned surveys, only 30 procedural skills were common in more than half of the propositioned lists in Canada [7] and 25 in the United States [8]. Practice location has been reported to influence clinical performance; for example, more skills are utilized more often in rural areas compared to urban regions. Clinical settings, such as training versus non-training hospitals or different tiers of healthcare facilities, would also be significant influencing factors, just to name a few [12,13].

There is no “correct answer” when it comes to defining essential topics and procedures; cultural differences with related lifestyle factors create different needs in different nations. Even within one country, “common” clinical issues and frequently applied medical skills are varied, as are community needs. Cost effectiveness is another factor to be considered, as well as the limited timeline available for residency training, which changes with the times.

Thus, it is not surprising that vast differences exist in the methodologies and participant demographics of previously developed “lists” between countries. For example, Canada, a front-runner in the field, even had different processes for selecting topics and procedures. For topics, a postal survey of write-in answers was sent to randomly selected 302 examiners in the certification examination of the College of Family Physicians of Canada; the response rate was 54% (n=163), and no demographic data were collected [1]. In selecting procedures, the Delphi technique was employed, with randomly chosen physicians asked to fill surveys to rate the procedures. Participants were evenly recruited from academic, urban, small town, and rural groups, and the total number of participants was 24 [7]. In the United States, an initial 2001 procedural survey was conducted with 326 residency program directors out of 467 [8]; the current consensus was developed by a subset of The Society of Teachers of Family Medicine Group on Hospital Medicine and Procedural Training consisting of 17 family physician educators with varied backgrounds and locations [9].

In our study, we were able to collect opinions from a diverse population of family physicians to form a consensus based on educational necessity and clinical utility specific to the current medical environment in Korea. This is the first attempt to define a set of essential clinical topics and procedural skills for family medicine residency training in Korea using opinions from physicians in various settings, representing the general family physicians of Korea. Our findings, similar to those of other studies, showed that educational expectations were much higher than actual personal performance [1].

There were some limitations in the development of the core lists. The biggest would be the relatively low response rates of the surveys, which could lessen the generalizability of the findings across the diversity of family medicine doctors throughout the nation. Availability of detailed demographic information of all 9,824 KAFM members (as of 2021) is limited due to restrictions on accessing personal information. However, gender composition and academic status is in the public domain. The majority of members (95.2%) have non-academic status, which shows discrepancy of approximately 50% with our survey responders. Second, collecting self-reported data, which was unavoidable due to the nature of the surveys, may have influenced the responses. Third, the pool of participants may be slightly biased; it can be deduced that the responses were submitted by individuals more interested in residency training than others.

However, our study has several strengths, such as the similar percentage of participation from the non-academic and academic sectors in the first and second surveys, which (had it been predominantly from academic participants) could otherwise may have led to very skewed results. Moreover, gender composition (40.0% female and 60.0% male) of all KAFM members is very similar to the composition of our first and second survey responders. The wide distribution of years in practice (new to over 20 years) also should help in identifying the needs of both young and new-generation doctors as well as benefiting from the time-proven wisdom of the old and experienced generation. Additionally, family medicine practitioners from various regions across the country, including metropolitan cities and rural provinces, participated in the survey from all tiers of healthcare facilities.

When commencing this investigation, the Working Group envisioned these lists to serve as a means of assessment or blueprint for residency training programs, especially with the upcoming transition to a novel competency-based educational curriculum for family medicine. In particular, the aim was to potentially help clarify the broad “mandatory (key) features” within the KAFM’s 15 entrustable professional activities; modifications and adjustments are ongoing to refine the lists for application.

In conclusion, the Working Group defined core lists of clinical topics and procedural skills for Korean family medicine residency training for the first time. The lists were derived based on the broadly agreeing opinions of diverse family medicine physicians across the nation belonging to a variety of clinical settings. Future application of these findings is expected to aid in effectively ensuring quality education in residency training and forming guidelines for training program evaluation. It is important to conduct further research, building on this preliminary study, to improve and refine the list.