Core outcomes for speech-language services in Ontario schools: a group concept mapping study and guiding framework.

BACKGROUND: Establishing the most important outcomes for school-based speech-language therapy is essential to guide future research and program evaluation for these services. Many health disciplines have developed core outcomes sets (COS) for this purpose. A COS encompasses the most important outcomes for particular health services as identified by appropriate interested parties. These interested parties usually represent health care providers and those with the health condition. In this paper, we report the development of a guiding framework for a COS for speech-language therapy services in schools in a Canadian context. METHODS: Using a group concept mapping method, we identified the outcomes for inclusion in the COS guiding framework through the elicited opinions of key interested parties: speech-language therapists, teachers, and family members of children with speech, language, and communication needs. We extracted 103 statements (potential outcomes) from a previous data set of interview transcripts. We then asked participants to sort the statements into conceptually similar groups, which were aggregated and transformed into a cluster map using multidimensional scaling followed by hierarchical cluster analysis. Participants also rated each statement on 5-point scales for importance and feasibility. We calculated mean ratings for individual statements and for all statements in a cluster, for all participants and for participant groups separately. RESULTS: We identified seven core outcomes for school-based speech-language services in Ontario, Canada. These included: classroom-based services, a holistic approach, support for teachers, care coordination, accessible services, family supports, and student success. All outcomes were rated highly for importance. Feasibility ratings were consistently below importance ratings. All participant groups concurred that a holistic approach was the most important outcome and accessible services was the least feasible outcome to achieve. CONCLUSIONS: The seven outcomes identified in this study are recommended to guide the development of a full COS to direct future research and program evaluation for school-based speech-language services. These outcomes have not been widely included in previous research and should be incorporated into future research alongside specific intervention outcomes. Data for some outcomes may be available from non-traditional sources such as administrative data sets. Consequently, their use for program evaluations should be accompanied by appropriate institutional support to allow speech-language therapists to make meaningful use of appropriate outcomes data.

Humanistic education in surgery: a "patient as teacher" program for surgical clerkship.

Summary: Surgeons are frequently perceived by medical students to be uncompassionate, resolute and individualistic. Surgical education often prioritizes teaching and learning approaches that perpetuate these perceptions. In other specialties, engaging patients in education has shown promise in refocusing attention from the technical and procedural aspects of care toward the humanistic and social aspects. Despite proven favourable outcomes for both patients and students in many clinical areas, a "patient as teacher" approach to surgical education has yet to be adopted widely in Canada. A patient as teacher program was developed for surgical clerks at the University of Toronto with the goal of emphasizing the humanity of the patient, the psychosocial impact of a surgical diagnosis of breast cancer on patients and their families, and the social and humanistic roles for surgeons in providing patient-centred care. We report on the program's development process and pilot session.

A Case Review: Reframing School-Based Practices Using a Critical Perspective.

It is well established in the literature that school-based practice is fraught with challenges such as acquisition of appropriate and sufficient resources, communication barriers among professionals, parental burden, and redundancies and gaps in services. The purpose of this perspective paper is to reframe potentially problematic school-based practices using a critical social science perspective, suggesting a vision and strategies for therapists working in the context of school-based practice. We illustrate our approach with a case example. To reframe school-based practices, we begin with Jill's case, exploring it through a critical lens to identify potential issues and opportunities for change. We then trace these findings to our larger dataset from an ongoing program of research to ensure relevance to the broader context of school-based practice. Reframing of three school-based practice issues is discussed from: (a) advocacy by proxy to collaborative dialogue, (b) governing texts to guiding texts, and (c) playing the "right" part to having a voice. Although this is a perspective paper based on a case exemplar, we posit how we may reframe and rethink school-based practices in pediatric rehabilitation. We suggest that only with a genuine shift in our professional values will we see the enactment of collaborative practice in school-based settings.

Exploring the utility of measures of critical thinking dispositions and professional behavior development in an audiology education program.

BACKGROUND: Discussions about professional behaviors are growing increasingly prevalent across health professions, especially as a central component to education programs. A strong critical thinking disposition, paired with critical consciousness, may provide future health professionals with a foundation for solving challenging practice problems through the application of sound technical skill and scientific knowledge without sacrificing sensitive, empathic, client-centered practice. In this article, we describe an approach to monitoring student development of critical thinking dispositions and key professional behaviors as a way to inform faculty members' and clinical supervisors' support of students and ongoing curriculum development. PURPOSE: We designed this exploratory study to describe the trajectory of change for a cohort of audiology students' critical thinking dispositions (measured by the California Critical Thinking Disposition Inventory: [CCTDI]) and professional behaviors (using the Comprehensive Professional Behaviors Development Log-Audiology [CPBDL-A]) in an audiology program. Implications for the CCTDI and CPBDL-A in audiology entry-to-practice curricula and professional development will be discussed. RESEARCH DESIGN: This exploratory study involved a cohort of audiology students, studied over a two-year period, using a one-group repeated measures design. STUDY SAMPLE: Eighteen audiology students (two male and 16 female), began the study. At the third and final data collection point, 15 students completed the CCTDI, and nine students completed the CPBDL-A. DATA COLLECTION AND ANALYSIS: The CCTDI and CPBDL-A were each completed at three time points: at the beginning, at the middle, and near the end of the audiology education program. Data are presented descriptively in box plots to examine the trends of development for each critical thinking disposition dimension and each key professional behavior as well as for an overall critical thinking disposition score. RESULTS: For the CCTDI, there was a general downward trend from time point 1 to time point 2 and a general upward trend from time point 2 to time point 3. Students demonstrated upward trends from the initial to final time point for their self-assessed development of professional behaviors as indicated on the CPBDL-A. CONCLUSIONS: The CCTDI and CPBDL-A can be used by audiology education programs as mechanisms for inspiring, fostering, and monitoring the development of critical thinking dispositions and key professional behaviors in students. Feedback and mentoring about dispositions and behaviors in conjunction with completion of these measures is recommended for inspiring and fostering these key professional attributes.

Three-year outcomes of transcatheter aortic valve implantation for bicuspid versus tricuspid aortic stenosis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) might be a feasible treatment option for more patients with bicuspid aortic valve (BAV) stenosis. However, long-term follow-up data in this population are scarce. AIMS: The aim of this study was to evaluate three-year outcomes after TAVI in patients with BAV. METHODS: A total of 246 consecutive patients who underwent TAVI at a single centre in China between March 2013 and February 2018 were enrolled in this study. Clinical outcomes, health status and echocardiography were followed and recorded for three years. RESULTS: Among 109 (44.3%) BAV patients, 61.5% were Type 0 and 36.7% were Type 1 BAV patients. BAV patients were younger (75 vs 77 years, p=0.041) and had a lower Society of Thoracic Surgeons (STS) score (5.09 vs 6.00, p=0.026) compared to tricuspid aortic valve (TAV) patients. There were no differences in three-year survival rates between bicuspid and tricuspid patients (87.1% vs 79.5%, log-rank p=0.126). Multivariate Cox regression analysis adjusting for confounding factors revealed a similar risk of all-cause mortality in the BAV population (hazard ratio [HR] 0.86, 95% confidence interval [CI]: 0.44-1.70, p=0.666). Except for the rate of permanent pacemaker implantation that was lower in BAV patients (11.9% vs 21.9%, p=0.041), the incidence of other clinical adverse events was comparable between the two groups. Both BAV and TAV patients showed an obvious improvement in valve haemodynamics, which was sustained for three years. In addition, similar left ventricular reverse remodelling was found during follow-up. CONCLUSIONS: BAV patients showed similar satisfactory three-year clinical outcomes, persistent valve haemodynamics improvement, and obvious cardiac reverse remodelling after TAVI compared to TAV patients.

Teaching health professionals how to tailor gender-affirming medicine protocols: A design thinking project.

BACKGROUND: Content knowledge surrounding transgender (trans) medicine is currently lacking in the formal medical education curricula. Evidence indicates that the main protocols used to assess and refer trans patients for gender-affirming medicine are misunderstood by health professionals, and require flexible adaptation to achieve health equity and patient-centred care. APPROACH: A free online educational tool for gender-affirming medicine, The Path to Patient-Centred Care, was developed to teach learners how to adapt assessment protocols. Resource creation was supported by a knowledge translation grant that endorsed design thinking, a human-centred and solutions-focused framework recommended for use in curriculum development. EVALUATION: The Path to Patient-Centred Care provides learners with information related to key principles of patient-centred care in gender-affirming medicine, including a guide on how to adapt the main assessment protocols to achieve equitable care. The curriculum also includes narratives from trans patients and health professionals that focus on health equity, and a clinical vignette about a complex case, designed to foster critical thinking on medical ethics. Project future directions involve an implementation and evaluation pilot study with a diverse group of continuing professional development medical learners using a mixed-methods program evaluation design. REFLECTION: The use of design thinking to develop this resource exemplifies a novel approach to curriculum development. By using pedagogical strategies that foster critical reflection, this innovative online education tool strives to teach self-directed learners how to provide care that emphasizes trans people's self-determination and autonomy in medical decision-making.

Exploring the Networking of Academic Health Science Leaders: How and Why Do They Do It?

PURPOSE: Networking is essential to leadership effectiveness in the business context. Yet little is known about leadership networking within the academic health science context. If we are going to train academic leaders, we must first understand the relational, network-based activities of their work. The purpose of this study was to explore how academic health science leaders engage in networking activities in the academic health science context. METHOD: A constructivist grounded theory approach guided our study. The authors interviewed 24 academic health science leaders who were enrolled in the New and Evolving Academic Leadership program at the University of Toronto and used social network mapping as an elicitation method. Interviews, which were conducted between September 2014 and June 2015, explored participants' networks and networking activities. Constant comparative analysis was used to analyze the interviews, with attention paid to identifying key networking activities. RESULTS: Academic health science leaders were found to engage in 4 types of networking activities: role bound, project based, goal/vision informed, and opportunity driven. These 4 types were influenced by participants' conception of their role and their perceived leadership work context, which in turn influenced their sense of agency. CONCLUSIONS: The networking activities identified in this study of academic health science leaders resonate with effective networking activities found in other fields. The findings highlight that these activities can be facilitated by focusing on leaders' perceptions about role and work context. Leadership development should thus attend to these perceptions to encourage effective networking skills.

Brain Injury After Transcatheter Replacement of Bicuspid Versus Tricuspid Aortic Valves.

BACKGROUND: An increasing number of bicuspid aortic valve (BAV) patients are undergoing transcatheter aortic valve replacement (TAVR), but the risk of brain injury in diffusion-weighted magnetic resonance imaging (DW-MRI) is currently unknown. OBJECTIVES: This study sought to evaluate the risk of brain injury in BAV patients following TAVR. METHODS: A total of 204 consecutive severe aortic stenosis patients who underwent TAVR were enrolled. A total of 83 (40.7%) patients were BAV patients, and the other 121 patients were tricuspid aortic valve (TAV) patients. All patients received DW-MRI at baseline, and after TAVR. RESULTS: Median ages (76 years [interquartile range (IQR): 71 to 81 years] vs. 79 years [IQR: 74 to 83 years]; p = 0.004) and Society of Thoracic Surgeons scores (4.87 [IQR: 3.72 to 8.54] vs. 6.38 [IQR: 3.96 to 9.50]; p = 0.044) of the BAV and TAV patients were significantly different, while the overt stroke rates (2.4% vs. 1.7%; p = 0.704) were comparable between the 2 groups. BAV patients were associated with higher number of new lesions (4.0 [IQR: 1.0 to 8.0] vs. 2.0 [IQR: 1.0 to 5.0]; p = 0.008), total lesion volume (290 mm3 [IQR: 70 to 930 mm3] vs. 140 mm3 [IQR: 35 to 480 mm3]; p = 0.008), and the volume per lesion (70.0 mm3 [IQR: 45.0 to 115.0 mm3] vs. 57.5 mm3 [IQR: 24.5 to 93.0 mm3]; p = 0.037) in DW-MRI. Moreover, the proportion of patients with lesions larger than 1 cm3 (28.6% vs. 10.9%; p = 0.005) was higher in BAV patients than in TAV patients. CONCLUSIONS: BAV patients may encounter more severe brain injuries not only due to greater number of lesions, but also due to larger lesion size in the early phase after TAVR. (Transcatheter Aortic Valve Replacement Single Center Registry in Chinese Population [TORCH]; NCT02803294).

Gaps in Developmental Pediatrics training: A Canadian resident physician perspective.

This article was migrated. The article was marked as recommended. Introduction: Postgraduate medical training worldwide has recently experienced a transition to Competency-Based Medical Education (CBME). This provides a timely opportunity to critically evaluate the postgraduate medical curriculum, particularly from a trainee perspective. Studies reveal that Canadian residents and recent graduates in pediatrics and family medicine are uncomfortable with their proficiency in child development. However, little is known about residents' perceptions of their training, nor where specific needs lie. We therefore sought to identify gaps in developmental pediatrics training, with the goal of informing the development of a new CBME curriculum. Methods: An online cross sectional needs assessment survey was administered to current pediatrics and family medicine residents at our institution. A total of 63 residents participated, 43 pediatrics and 20 family medicine. Results: Four key themes emerged from analysis of survey results: 1. Residents agree that developmental pediatrics is relevant to future practice and competency; 2. Residents feel they lack competency in the assessment and management of patients with developmental issues; 3. Residents' feelings of insufficient and inadequate training increase over time; 4. Residents recommend changes to developmental pediatrics training. Conclusion: As we prepare to transition to CBME, curriculum should be purposefully developed to meet resident identified need and reflect appropriate competencies required for clinical practice.

Compassionate Care in the Age of Evidence-Based Practice: A Critical Discourse Analysis in the Context of Chronic Pain Care.

PURPOSE: Health professions education and practice have seen renewed calls to restore compassion to care. However, because of the ways evidence-based practice (EBP) has been implemented in health care, wherein research-based knowledge is privileged, the dominance of EBP may silence clinician and patient experience-based knowledge needed for compassionate care. This study explored what happens when the discourses of compassionate care and EBP interact in practice. METHOD: Chronic pain management in Canada was selected as the context for the study. Data collection involved compiling an archive of 458 chronic pain texts, including gray literature from 2009-2015 (non-peer-reviewed sources, e.g., guidelines), patient blog posts from 2013-2015, and transcripts of study interviews with 9 clinicians and postgraduate trainees from local pain clinics from 2015-2016. The archive was analyzed using an interpretive qualitative approach informed by critical discourse analysis. RESULTS: Four manifestations of the discourse of compassionate care were identified: curing the pain itself, returning to function, alleviating suffering, and validating the patient experience. These discourses produced particular subject positions, activities, practices, and privileged forms of knowledge. They operated in response, partnership, apology, and resistance, respectively, to the dominant discourse of EBP. These relationships were mediated by other prevalent discourses in the system: patient safety, patient-centered care, professional liability, interprofessional collaboration, and efficiency. CONCLUSIONS: Medical education efforts to foster compassion in health professionals and systems need to acknowledge the complex web of discourses-which carry with them their own expectations, material effects, and roles-and support people in navigating this web.

Faculty and resident perspectives on ambulatory care education: A collective case study of family medicine, psychiatry, and surgery.

BACKGROUND: Ambulatory care (AC) experiences within medical education are garnering increasing attention. We sought to understand how faculty and residents' describe their experiences of AC and ambulatory care education (ACEduc) within, between, and across disciplinary contexts. METHODS: We designed a Stakian collective case study, applying constructivist grounded theory analytic methods. Using purposive and snowball sampling, we interviewed 17 faculty and residents across three instrumental cases: family medicine, psychiatry, surgery. Through constant comparative analysis, we identified patterns within, between, and across cases. RESULTS: Family medicine and psychiatry saw AC as an inherent part of continuous, longitudinal care; surgery equated AC with episodic experiences in clinic, differentiating it from operating. Across cases, faculty and residents cautiously valued ACEduc, and in particular, considered it important to develop non-medical expert competencies (e.g., communication). However, surgery residents described AC and ACEduc as less interesting and a lower priority than operating. Educational structures mediated these views. CONCLUSION: Differences between cases highlight a need for further study, as universal assumptions about ACEduc's purposes and approaches may need to be tempered by situated, contextually-rich perspectives. How disciplinary culture, program structure, and systemic structure influence ACEduc warrant further consideration as does the educational potential for explicitly framing learners' perspectives.