Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review update: BEME Guide No. 85.

BACKGROUND: Clinical teachers often struggle to record trainee underperformance due to lacking evidence-based remediation options. OBJECTIVES: To provide updated evidence-based recommendations for addressing academic difficulties among undergraduate and postgraduate medical learners. METHODS: A systematic review searched databases including MEDLINE, CINAHL, EMBASE, ERIC, Education Source, and PsycINFO (2016-2021), replicating the original Best Evidence Medical Education 56 review strategy. Original research/innovation reports describing intervention(s) for medical learners with academic difficulties were included. Data extraction used Michie's Behaviour Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraised used the Mixed Methods Appraisal Tool (MMAT). Authors synthesized extracted evidence by adapting GRADE approach to formulate recommendations. RESULTS: Eighteen articles met the inclusion criteria, primarily addressing knowledge (66.7%), skills (66.7%), attitudinal problems (50%) and learner's personal challenges (27.8%). Feedback and monitoring was the most frequently employed BCT. Study quality varied (MMAT 0-100%). We identified nineteen interventions (UG: n = 9, PG: n = 12), introducing twelve new thematic content. Newly thematic content addressed contemporary learning challenges such as academic procrastination, and use of technology-enhanced learning resources. Combined with previous interventions, the review offers a total dataset of 121 interventions. CONCLUSION: This review offers additional evidence-based interventions for learners with academic difficulties, supporting teaching, learning, faculty development, and research efforts.

Measuring Health Care Work-Related Contextual Factors: Development of the McGill Context Tool.

INTRODUCTION: Contextual factors can influence healthcare professionals' (HCPs) competencies, yet there is a scarcity of research on how to optimally measure these factors. The aim of this study was to develop and validate a comprehensive tool for HCPs to document the contextual factors likely to influence the maintenance, development, and deployment of professional competencies. METHODS: We used DeVellis' 8-step process for scale development and Messick's unified theory of validity to inform the development and validation of the context tool. Building on results from a scoping review, we generated an item pool of contextual factors articulated around five themes: Leadership and Agency, Values, Policies, Supports, and Demands. A first version of the tool was pilot tested with 127 HCPs and analyzed using the classical test theory. A second version was tested on a larger sample (n = 581) and analyzed using the Rasch rating scale model. RESULTS: First version of the tool: we piloted 117 items that were grouped as per the themes related to contextual factors and rated on a 5-point Likert scale. Cronbach alpha for the set of 12 retained items per scale ranged from 0.75 to 0.94. Second version of the tool included 60 items: Rasch analysis showed that four of the five scales (ie, Leadership and Agency, Values, Policies, Supports) can be used as unidimensional scales, whereas the fifth scale (Demands) had to be split into two unidimensional scales (Demands and Overdemands). DISCUSSION: Validity evidence documented for content and internal structure is encouraging and supports the use of the McGill context tool. Future research will provide additional validity evidence and cross-cultural translation.

[Feedback Guide for direct observation of family medicine residents in Canada: a francophone tool]. / Développement et mise à l'essai du Guide de rétroaction francophone pour l'observation directe des résidents en médecine familiale au Canada.

Background: There is no CanMEDS-FM-based milestone tool to guide feedback during direct observation (DO). We have developed a guide to support documentation of feedback for direct observation (DO) in Canadian family medicine (FM) programs. Methods: The Guide was designed in three phases with the collaboration of five Canadian FM programs with at least a French-speaking teaching site: 1) literature review and needs assessment; 2) development of the DO Feedback Guide; 3) testing the Guide in a video simulation context with qualitative content analysis. Results: Phase 1 demonstrated the need for a narrative guide aimed at 1) specifying mutual expectations according to the resident's level of training and the clinical context, 2) providing the supervisor with tools and structure in his observations 3) to facilitate documentation of feedback. Phase 2 made it possible to develop the Guide, in paper and electronic formats, meeting the needs identified. In phase 3, 15 supervisors used the guide for three levels of residence. The Guide was adjusted following this testing to recall the phases of the clinical encounter that were often forgotten during feedback (before consultation, diagnosis and follow-up), and to suggest types of formulation to be favored (stimulating questions, questions of clarification, reflections). Conclusion: Based on evidence and a collaborative approach, this Guide will equip French-speaking Canadian supervisors and residents performing DO in family medicine.

Psychometric validation of the Laval developmental benchmarks scale for family medicine.

BACKGROUND: With the implementation of competency-based education in family medicine, there is a need for summative end-of-rotation assessments that are criterion-referenced rather than normative. Laval University's family residency program therefore developed the Laval Developmental Benchmarks Scale for Family Medicine (DBS-FM), based on competency milestones. This psychometric validation study investigates its internal structure and its relation to another variable, two sources of validity evidence. METHODS: We used assessment data from a cohort of residents (n = 1432 assessments) and the Rasch Rating Scale Model to investigate its reliability, dimensionality, rating scale functioning, targeting of items to residents' competency levels, biases (differential item functioning), items hierarchy (adequacy of milestones ordering), and score responsiveness. Convergent validity was estimated by its correlation with the clinical rotation decision (pass, in difficulty/fail). RESULTS: The DBS-FM can be considered as a unidimensional scale with good reliability for non-extreme scores (.83). The correlation between expected and empirical items hierarchies was of .78, p < .0001.Year 2 residents achieved higher scores than year 1 residents. It was associated with the clinical rotation decision. CONCLUSION: Advancing its validation, this study found that the DBS-FM has a sound internal structure and demonstrates convergent validity.

CanMEDS Competencies in Family Medicine Residents: Can Criterion-Based Assessment Improve the Quality of Teacher Feedback?

This article was migrated. The article was marked as recommended. Background: The Université Laval family medicine program has developed an innovative computerized tool called the criterion-based Competency Assessment Tool (CAT), currently undergoing validity assessment. Methods: This study followed a qualitative design assessing written comments collected in the assessment reports from the cohorts before and after the implementation of the CAT (n pre = 200, n post = 200) in order to ascertain the tool's consequence validity. A deductive thematic content analysis was performed and pre- and post-implementation cohorts were compared. Findings: Overall feedback quality does not appear to have changed between cohorts. When analyzing CanMEDS roles separately, each is covered more often, but related comments appear to be less specific. The new report also seems to enable the teacher to tell more with the same number of words. Conclusions: Perhaps since the items are complete, exhaustive, and detailed enough to be self-explanatory, the tool helps the teacher to cover a wider area of competencies without the need to add many details with narrative comments. Consequence validity does not seem to have been substantially affected by changes in the family medicine resident's competency assessment, but the results do not support the contention that comment quality has improved either.

Supporting early academic family medicine careers with the clinician scholar enhanced-skills program.

CONTEXT: The Clinician Scholar Program (CSP) is an enhanced-skills (R3) residency program to train clinician researchers/educators/leaders for academic family practice. This article intends to share Laval University's CSP development and evaluation strategy, and provide recommendations for similar innovations in other disciplines/settings. METHODS: This article uses Kern's model to present the program development, and a program-oriented approach for program evaluation, carried from 2011 to 2017 using descriptive data. Questionnaires, reflexive texts and an Objective Structured Teaching Exam supported data collection. RESULTS: Seven CSP graduates and 14 controls participated in the program evaluation. Residents were highly satisfied with the program, nevertheless they suggested to allow physicians to come back for training later in career. The CSP enriched knowledge, skills and attitudes about academic practice. CSP increased residents' entrustment level about academic competencies. All graduates joined an academic practice within five years of program completion. CONCLUSION: Key recommendations to implement similar programs include academic medicine core training, project- based learning with learner-centered objectives, relevant and authentic learning and assessment, and multi-level program evaluation approach. Programs should consider concomitant graduate studies and opportunity to offer such training after a few years of clinical practice to meet other needs at a timely stage of career.

CONTEXTE: Le programme clinicien érudit (PCÉ) est un programme de résidence de compétences avancées (R3) destiné à former des cliniciens chercheurs / éducateurs / leaders en vue d'une pratique de médecine familiale universitaire. Cet article a pour but de faire connaître la stratégie de développement et d'évaluation du PCÉ de l'Université Laval et de formuler des recommandations pour des innovations similaires dans d'autres disciplines/contextes. MÉTHODES: Cet article utilise le modèle de Kern pour présenter le développement du programme et une approche d'évaluation orientée sur le programme, réalisée de 2011 à 2017 à l'aide de données descriptives. Des questionnaires, des textes réflexifs et un examen d'enseignement objectif structuré ont permis de recueillir des données. RÉSULTATS: Sept diplômés du PCÉ et 14 témoins ont participé à l'évaluation du programme. Les résidents étaient très satisfaits du programme, suggérant néanmoins de permettre une formation plus tard dans la carrière. Le PCÉ a enrichi les connaissances, les habiletés et les attitudes relatives à la pratique universitaire. Le PCÉ a augmenté le niveau de confiance des résidents en ce qui concerne les compétences académiques. Tous les diplômés se sont engagés dans une pratique universitaire dans les cinq années suivant leur graduation du programme. CONCLUSIONS: Les principales recommandations pour la mise en œuvre de programmes similaires incluent la réalisation d'un tronc commun en médecine universitaire, l'apprentissage par projet avec des objectifs centrés sur l'apprenant, des stratégies d'apprentissage et d'évaluation pertinentes et authentiques, et une approche d'évaluation de programme à plusieurs niveaux. Les programmes doivent envisager offrir des études supérieures en parallèle et la possibilité d'offrir cette formation après quelques années de pratique clinique afin de répondre à d'autres besoins à un stade opportun de leur carrière.

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review: BEME Guide No. 56.

Background: Clinical teachers often struggle to report unsatisfactory trainee performance, partly because of a lack of evidence-based remediation options. Objectives: To identify interventions for undergraduate (UG) and postgraduate (PG) medical learners experiencing academic difficulties, link them to a theory-based framework and provide literature-based recommendations around their use. Methods: This systematic review searched MEDLINE, CINAHL, EMBASE, ERIC, Education Source and PsycINFO (1990-2016) combining these concepts: medical education, professional competence/difficulty and educational support. Original research/innovation reports describing intervention(s) for UG/PG medical learners with academic difficulties were included. Data extraction employed Michie's Behavior Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraisal used the Mixed Methods Appraisal Tool (MMAT). The authors synthesized extracted evidence by adapting the GRADE approach to formulate recommendations. Results: Sixty-eight articles met the inclusion criteria, most commonly addressing knowledge (66.2%), skills (53.9%) and attitudinal problems (26.2%), or learner personal issues (41.5%). The most common BCTs were Shaping knowledge, Feedback/monitoring, and Repetition/substitution. Quality appraisal was variable (MMAT 0-100%). A thematic content analysis identified 109 interventions (UG: n = 84, PG: n = 58), providing 24 strong, 48 moderate, 26 weak and 11 very weak recommendations. Conclusion: This review provides a repertoire of literature-based interventions for teaching/learning, faculty development, and research purposes.

Twelve tips for efficient procedural simulation.

Procedural simulation (PS) is increasingly being used worldwide in healthcare for training caregivers in psychomotor competencies. It has been demonstrated to improve learners' confidence and competence in technical procedures, with consequent positive impacts on patient outcomes and safety. Several frameworks can guide healthcare educators in using PS as an educational tool. However, no theory-informed practical framework exists to guide them in including PS in their training programs. We present 12 practical tips for efficient PS training that translates educational concepts from theory to practice, based on the existing literature. In doing this, we aim to help healthcare educators to adequately incorporate and use PS both for optimal learning and for transfer into professional practice.

The Application of Entrustable Professional Activities to Inform Competency Decisions in a Family Medicine Residency Program.

Assessing entrustable professional activities (EPAs), or carefully chosen units of work that define a profession and are entrusted to a resident to complete unsupervised once she or he has obtained adequate competence, is a novel and innovative approach to competency-based assessment (CBA). What is currently not well described in the literature is the application of EPAs within a CBA system. In this article, the authors describe the development of 35 EPAs for a Canadian family medicine residency program, including the work by an expert panel of family physician and medical education experts from four universities in three Canadian provinces to identify the relevant EPAs for family medicine in nine curriculum domains. The authors outline how they used these EPAs and the corresponding templates that describe competence at different levels of supervision to create electronic EPA field notes, which has allowed educators to use the EPAs as a formative tool to structure day-to-day assessment and feedback and a summative tool to ground competency declarations about residents. They then describe the system to compile, collate, and use the EPA field notes to make competency declarations and how this system aligns with van der Vleuten's utility index for assessment (valid, reliable, of educational value, acceptable, cost-effective). Early outcomes indicate that preceptors are using the EPA field notes more often than they used the generic field notes. EPAs enable educators to evaluate multiple objectives and important but unwieldy competencies by providing practical, manageable, measurable activities that can be used to assess competency development.

Expectations of clinical teachers and faculty regarding development of the CanMEDS-Family Medicine competencies: Laval developmental benchmarks scale for family medicine residency training.

BACKGROUND: The CanMEDS-Family Medicine (CanMEDS-FM) framework defines the expected terminal enabling competencies (EC) for family medicine (FM) residency training in Canada. However, benchmarks throughout the 2-year program are not yet defined. PURPOSES: This study aimed to identify expected time frames for achievement of the CanMEDS-FM competencies during FM residency training and create a developmental benchmarks scale for family medicine residency training. METHODS: This 2011-2012 study followed a Delphi methodology. Selected faculty and clinical teachers identified, via questionnaire, the expected time of EC achievement from beginning of residency to one year in practice (0, 6, 12, […] 36 months). The 15-85th percentile intervals became the expected competency achievement interval. Content validity of the obtained benchmarks was assessed through a second Delphi round. RESULTS: The 1st and 2nd rounds were completed by 33 and 27 respondents, respectively. A developmental benchmarks scale was designed after the 1st round to illustrate expectations regarding achievement of each EC. The 2nd round (content validation) led to minor adjustments (1.9±2.7 months) of intervals for 44 of the 92 competencies, the others remaining unchanged. CONCLUSIONS: The Laval Developmental Benchmarks Scale for Family Medicine clarifies expectations regarding achievement of competencies throughout FM training. In a competency-based education system this now allows identification and management of outlying residents, both those excelling and needing remediation. Further research should focus on assessment of the scale reliability after pilot implementation in family medicine clinical teaching units at Laval University, and corroborate the established timeline in other sites.

Using field notes to evaluate competencies in family medicine training: a study of predictors of intention.

BACKGROUND: Documenting feedback during clinical supervision using field notes (FN) is a recommended competency-based evaluation strategy that will require changes in the culture of medical education. This study identified factors influencing the intention to adopt FN in family medicine training, using the theory of planned behaviour. METHODS: This mixed-methods study involved clinical teachers (CT) and residents from two family medicine units. Main outcomes were: 1) intention (and its predictors: attitude, perceived behavioural control (PBC) and normative belief) to use FN, assessed using a 7-item Likert scale questionnaire (1: strongly disagree to 7: strongly agree) and 2) related salient beliefs, explored in focus groups three and six months after FN implementation. RESULTS: 27 CT and 28 residents participated. Intention to use FN was 6.20±1.20 and 5.74±1.03 in CT and residents respectively. Predictors of this intention were attitude and PBC (mutually influential: p < 0.05), and normative belief (p < 0.01). Focus groups identified underlying beliefs regarding their use (perceived advantages/disadvantages and facilitators/barriers). CONCLUSION: Intention to adopt field notes to document competency is influenced by attitude, perceived behavioural control and normative belief. Implementation of field notes should be preceded by interventions that target the identified salient beliefs to improve this competency-based evaluation strategy.

Integrating teaching into the busy resident schedule: a learner-centered approach to raise efficiency (L-CARE) in clinical teaching.

BACKGROUND: Clinical teachers are sometimes challenged by residents who seem too busy to concentrate on their learning. In such situations, teachers must be aware to diagnose underlying problems in learners and to effectively help them maximize learning while minimizing time and energy requirements. OBJECTIVE: To develop a learner-centered model to improve efficiency of clinical teaching. METHODS: We reviewed the literature on educational diagnosis, self-directed learning, and effective/efficient teaching to put together a new model. RESULTS: The Learner-Centered Approach to Raise Efficiency (L-CARE) in Clinical Teaching is inspired from the well-known patient-centered clinical method. Using the L-CARE in clinical teaching involves: (1) addressing the learners' feelings regarding their environment as well as patient care and study issues, which provides a good learning climate facilitating educational diagnosis and management of issues that could impair learning; (2) establishing a learning contract (expectations); (3) sharing resources and strategies (ideas) that should be effective without wasting time or energy; (4) self-assessment and constructive feedback (impact). These steps are grounded in self-directed learning theory to improve motivation and ensure that learners concentrate on their own needs to promote learning efficiency. CONCLUSION: The L-CARE model integrates educational diagnosis principles, self-directed learning theory, and efficient teaching strategies to improve efficiency of clinical teaching.

Teaching-skills training programs for family medicine residents: systematic review of formats, content, and effects of existing programs.

OBJECTIVE: To review the literature on teaching-skills training programs for family medicine residents and to identify formats and content of these programs and their effects. DATA SOURCES: Ovid MEDLINE (1950 to mid-July 2008) and the Education Resources Information Center database (pre-1966 to mid-July 2008) were searched using and combining the MeSH terms teaching, internship and residency, and family practice; and teaching, graduate medical education, and family practice. STUDY SELECTION: The initial MEDLINE and Education Resources Information Center database searches identified 362 and 33 references, respectively. Titles and abstracts were reviewed and studies were included if they described the format or content of a teaching-skills program or if they were primary studies of the effects of a teaching-skills program for family medicine residents or family medicine and other specialty trainees. The bibliographies of those articles were reviewed for unidentified studies. A total of 8 articles were identified for systematic review. Selection was limited to articles published in English. SYNTHESIS: Teaching-skills training programs for family medicine residents vary from half-day curricula to a few months of training. Their content includes leadership skills, effective clinical teaching skills, technical teaching skills, as well as feedback and evaluation skills. Evaluations mainly assessed the programs' effects on teaching behaviour, which was generally found to improve following participation in the programs. Evaluations of learner reactions and learning outcomes also suggested that the programs have positive effects. CONCLUSION: Family medicine residency training programs differ from all other residency training programs in their shorter duration, usually 2 years, and the broader scope of learning within those 2 years. Few studies on teaching-skills training, however, were designed specifically for family medicine residents. Further studies assessing the effects of teaching-skills training in family medicine residents are needed to stimulate development of adapted programs for the discipline. Future research should also assess how residents' teaching-skills training can affect their learners' clinical training and eventually patient care.

Chronic obstructive pulmonary disease in women.

BACKGROUND: Little is known about the comparative impact of chronic obstructive pulmonary disease (COPD) between women and men and about women's response to pulmonary rehabilitation. OBJECTIVES: To compare lung function, disability, mortality and response to pulmonary rehabilitation between women and men with COPD. METHODS: In the present retrospective study, 68 women (mean age 62.5+/-8.9 years) and 168 men (mean age 66.3+/-8.4 years) were evaluated by means of pulmonary function testing and an incremental symptom-limited cycle exercise test. Forty women and 84 men also participated in a 12-week pulmonary rehabilitation program. A 6 min walking test and the chronic respiratory questionnaire were used to assess the effects of pulmonary rehabilitation. Survival status was also evaluated. RESULTS: Compared with men, women had a smaller tobacco exposure (31+/-24 versus 48+/-27 pack-years, P<0.05), displayed better forced expiratory volume in 1 s (44+/-13 versus 39+/-14 % predicted, P<0.05), a higher functional residual capacity (161+/-37 versus 149+/-36 % predicted, P<0.05) and total lung capacity (125+/-20 versus 115+/-19 % predicted, P<0.001). Peak oxygen consumption was not different between women and men when expressed in predicted values but lower in women when expressed in absolute values. Pulmonary rehabilitation resulted in significant improvements in 6 min walking test and quality of life in both sexes, but women had a greater improvement in chronic respiratory questionnaire dyspnea. Survival status was similar between sexes, but predictors of mortality were different between sexes. CONCLUSIONS: Women may be more susceptible to COPD than men. The clinical expression of COPD may differ between sexes with greater degree of hyperinflation in women, who also benefit from pulmonary rehabilitation.