Comparison of peer-assisted learning with expert-led learning in medical school ultrasound education: a systematic review and meta-analysis.

INTRODUCTION: Teaching point-of-care ultrasonography (PoCUS) to medical students is resource intensive. Peer-assisted learning, where the teacher can be a medical student, may be a feasible alternative to expert-led learning. The objective of this systematic review and meta-analysis was to compare the PoCUS performance assessments of medical students receiving peer-assisted vs expert-led learning. METHODS: This study was submitted to PROSPERO (CRD42023383915) and reported with PRISMA guidelines. MEDLINE, Embase, ERIC, Education Source, Scopus, and Web of Science were searched from inception to November 2022. Inclusion criteria were studies comparing peer-assisted vs expert-led PoCUS teaching for undergraduate medical students. The primary outcome was performance assessment of PoCUS skills. Two reviewers independently screened citations and extracted data. The Cochrane risk-of-bias tool for randomized trials was used to assess study quality. Studies were included in the meta-analysis if mean performance assessment scores with standard deviations and sample sizes were available. A random-effects meta-analysis was conducted to estimate the accuracy score of practical knowledge test for each group. A meta-regression evaluated difference in mean scores. RESULTS: The search yielded 2890 citations; 1417 unique citations remained after removing duplicates. Nine randomized-controlled studies conducted in Germany, USA, and Israel, with 593 participants, were included in the meta-analysis. The included studies assessed teaching of abdominal, cardiac, thoracic, musculoskeletal, and ocular PoCUS skills. Most studies had some risk-of-bias concerns. The estimate accuracy score after weighting is 0.56 (95% CI [0.47, 0.65]) for peer-assisted learning and 0.59 (95% CI [0.49, 0.69]) for expert-led learning. The regression coefficient estimate is 0.0281 (95% CI [- 0.1121, 0.1683]); P value is 0.69. CONCLUSION: This meta-analysis found that peer-assisted learning was a reasonable alternative to expert-led learning for teaching PoCUS skills to medical students.

RéSUMé: INTRODUCTION: L'enseignement de l'échographie au point d'intervention (PoCUS) aux étudiants en médecine nécessite des ressources importantes. L'apprentissage assisté par les pairs, où l'enseignant peut être un étudiant en médecine, peut être une alternative possible à l'apprentissage dirigé par des experts. L'objectif de cette revue systématique et de cette méta-analyse était de comparer les évaluations de performance PoCUS d'étudiants en médecine bénéficiant d'un apprentissage assisté par des pairs par rapport à un apprentissage dirigé par des experts. MéTHODES: Cette étude a été soumise à PROSPERO (CRD42023383915) et rapportée selon les directives PRISMA. MEDLINE, Embase, ERIC, Education Source, Scopus et Web of Science ont été recherchés depuis leur création jusqu'en novembre 2022. Les critères d'inclusion étaient les études comparant l'enseignement du PoCUS assisté par des pairs à celui dirigé par des experts pour les étudiants en médecine de premier cycle. Le principal résultat était l'évaluation du rendement des compétences PoCUS. Deux évaluateurs ont indépendamment examiné les citations et extrait les données. L'outil Cochrane d'évaluation du risque de biais pour les essais randomisés a été utilisé pour évaluer la qualité des études. Les études ont été incluses dans la méta-analyse si les scores moyens d'évaluation des performances avec les écarts types et la taille des échantillons étaient disponibles. Une méta-analyse à effets aléatoires a été réalisée pour estimer le score de précision du test de connaissances pratiques pour chaque groupe. Une méta-régression a évalué la différence dans les scores moyens. RéSULTATS: La recherche a donné lieu à 2890 citations ; 1417 citations uniques ont été conservées après suppression des doublons. Neuf études contrôlées randomisées menées en Allemagne, aux États-Unis et en Israël, avec 593 participants, ont été incluses dans la méta-analyse. Les études incluses ont évalué l'enseignement des compétences PoCUS abdominales, cardiaques, thoraciques, musculo-squelettiques et oculaires. La plupart des études présentaient des risques de biais. Le score de précision estimé après pondération est de 0,56 (IC à 95 % : [0,47, 0,65]) pour l'apprentissage assisté par les pairs et de 0,59 (IC à 95 % : [0,49, 0,69]) pour l'apprentissage dirigé par des experts. L'estimation du coefficient de régression est de 0,0281 (IC à 95 % : [-0,1121, 0,1683]) ; la valeur P est de 0,69. CONCLUSION: Cette méta-analyse a montré que l'apprentissage assisté par les pairs était une alternative raisonnable à l'apprentissage dirigé par des experts pour enseigner les compétences PoCUS aux étudiants en médecine.

Point-of-Care-ultrasound in undergraduate medical education: a scoping review of assessment methods.

BACKGROUND: Point-of-Care-Ultrasound (POCUS) curricula have rapidly expanded in undergraduate medical education (UME). However, the assessments used in UME remain variable without national standards. This scoping review characterizes and categorizes current assessment methods using Miller's pyramid for skills, performance, and competence of POCUS in UME. A structured protocol was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). A literature search of MEDLINE was performed from January 1, 2010, to June 15, 2021. Two independent reviewers screened all titles and abstracts for articles that met inclusion criteria. The authors included all POCUS UME publications in which POCUS-related knowledge, skills, or competence were taught and objectively assessed. Articles were excluded if there were no assessment methods used, if they exclusively used self-assessment of learned skills, were duplicate articles, or were summaries of other literature. Full text analysis and data extraction of included articles were performed by two independent reviewers. A consensus-based approach was used to categorize data and a thematic analysis was performed. RESULTS: A total of 643 articles were retrieved and 157 articles met inclusion criteria for full review. Most articles (n = 132; 84%) used technical skill assessments including objective structured clinical examinations (n = 27; 17%), and/or other technical skill-based formats including image acquisition (n = 107; 68%). Retention was assessed in n = 98 (62%) studies. One or more levels of Miller's pyramid were included in 72 (46%) articles. A total of four articles (2.5%) assessed for students' integration of the skill into medical decision making and daily practice. CONCLUSIONS: Our findings demonstrate a lack of clinical assessment in UME POCUS that focus on integration of skills in daily clinical practice of medical students corresponding to the highest level of Miller's Pyramid. There exists opportunities to develop and integrate assessment that evaluate higher level competencies of POCUS skills of medical students. A mixture of assessment methods that correspond to multiple levels of Miller's pyramid should be used to best assess POCUS competence in UME.

Canadian Association of Radiologists Diagnostic Imaging Referral Guidelines: a guideline development protocol.

BACKGROUND: Comprehensive diagnostic imaging referral guidelines are an important tool to assist referring clinicians and radiologists in determining the safest and best-clinical-value diagnostic imaging study for their patients; the Canadian Association of Radiologists (CAR) last produced its diagnostic imaging referral guidelines in 2012. In partnership with several national organizations, referring clinicians, radiologists, and patient and family advisors from across Canada, the association is redoing its referral guidelines using a new methodology for guideline development, and these guideline recommendations will be suited for integration into clinical decision support systems. METHODS: Expert panels of radiologists, referring clinicians and a patient advisor will work with epidemiologists at the CAR to create guidelines across 13 clinical sections. The expert panel for each section will first create a comprehensive list of clinical and diagnostic scenarios to include in the guidelines. Canadian Association of Radiologists epidemiologists will then conduct a systematic rapid scoping review to identify systematically produced guidelines from other guideline groups. The corresponding expert panel will develop diagnostic imaging recommendations for each clinical and diagnostic scenario using the recommendations identified from the scoping review and contextualize them to the Canadian health care systems. The expert panels will accomplish this using an adapted Grading of Recommendations Assessment, Development and Evaluation framework, which reflects the benefits and harms, values and preferences, equity, accessibility, resources and cost. INTERPRETATION: Freely available, up-to-date, comprehensive Canadian-specific diagnostic imaging referral guidelines are needed. A transparent and structured guideline-development approach will aid the CAR and its partners in producing guidelines across its 13 sections.

Using Kane's framework to build an assessment tool for undergraduate medical student's clinical competency with point of care ultrasound.

INTRODUCTION: Point-of-care ultrasonography (POCUS) is a portable imaging technology used in clinical settings. There is a need for valid tools to assess clinical competency in POCUS in medical students. The primary aim of this study was to use Kane's framework to evaluate an interpretation-use argument (IUA) for an undergraduate POCUS assessment tool. METHODS: Participants from Memorial University of Newfoundland, the University of Calgary, and the University of Ottawa were recruited between 2014 and 2018. A total of 86 participants and seven expert raters were recruited. The participants performed abdominal, sub-xiphoid cardiac, and aorta POCUS scans on a volunteer patient after watching an instruction video. The participant-generated POCUS images were assessed by the raters using a checklist and a global rating scale. Kane's framework was used to determine validity evidence for the scoring inference. Fleiss' kappa was used to measure agreement between seven raters on five questions that reflected clinical competence. The descriptive comments collected from the raters were systematically coded and analyzed. RESULTS: The overall agreement between the seven raters on five questions on clinical competency ranged from fair to moderate (κ = 0.32 to 0.55). The themes from the qualitative data were poor image generation and interpretation (22%), items not applicable (20%), poor audio and video quality (20%), poor probe handling (10%), and participant did not verbalize findings (14%). CONCLUSION: The POCUS assessment tool requires further modification and testing prior before it can be used for reliable undergraduate POCUS assessment.

Test Characteristics of Chest Ultrasonography for Rib Fractures Following Blunt Chest Trauma: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: Chest ultrasonography has been reported as an accurate imaging modality and potentially superior to chest radiographs in diagnosing traumatic rib fractures. However, few studies have compared ultrasonography to the reference standard of computed tomography (CT), with no systematic reviews published on the topic to date. Our objective was to summarize the evidence comparing the test characteristics of chest ultrasonography to CT in diagnosing rib fractures. METHODS: This study was performed and reported in adherence to PRISMA guidelines. We searched 5 databases plus gray literature from inception to October 2021. Two independent reviewers completed study selection, data extraction, and a QUADAS-2 risk of bias assessment. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model. RESULTS: From 1,660 citations, we identified 7 studies for inclusion, of which 6 had available 2×2 data for meta-analysis (n = 663). Of the 6 studies, 3 involved emergency department-performed ultrasonography and 3 radiology-performed ultrasonography. Chest ultrasonography had a pooled sensitivity of 89.3% (95% confidence interval [CI], 81.1 to 94.3) and specificity of 98.4% (95% CI, 90.2 to 99.8) compared with CT imaging for the diagnosis of any rib fracture. The finding of a fracture on ultrasonography, defined as an underlying cortical irregularity, was associated with a +likelihood ratio (LR) of 55.7 (95% CI, 8.5 to 363.4) for CT diagnosed rib fracture, while the absence of ultrasonography fracture held a -LR of 0.11 (95% CI, 0.06 to 0.20). We were unable to detect a difference in test characteristics between emergency department- and radiology-performed ultrasonography (P=.11). The overall risk of bias of included studies was high, with patient selection identified as the highest risk domain. CONCLUSION: Chest ultrasonography is both sensitive and highly specific in diagnosing rib fractures following blunt trauma.

Characterizing the biomechanical differences between novice and expert point-of-care ultrasound practitioners using a low-cost gyroscope and accelerometer integrated sensor: A pilot study.

Introduction: Point-of-care ultrasound (POCUS) has become an important diagnostic tool in acute care medicine; however, little is known about the biomechanical differences between novice and expert practitioners. Methods: A low-cost ($50 CAD) gyroscope and accelerometer integrated sensor was assembled and affixed to an ultrasound probe. Seventeen participants, nine novices and eight experts, were recruited to perform three abdominal and four cardiac scans on a standardized patient. Participant demographics, time per scan, average acceleration, average angular velocity, decay in acceleration and angular velocity over time, and frequency of probe movements were analyzed. Video capture with blinded video review was scored. Results: On video review, experts had higher image optimization and acquisition scores for both abdominal and cardiac scans. Experts had shorter scan times for abdominal (7 s vs. 26 s, p = 0.003) and cardiac (11 s vs. 26 s, p < 0.001) scans. There was no difference in average acceleration (g) between novices and experts performing abdominal (1.02 vs. 1.01, p = 0.50) and cardiac (1.01 vs. 1.01, p = 0.45) scans. Experts had lower angular velocity (°/s) for abdominal scans (10.00 vs. 18.73, p < 0.001) and cardiac scans (15.61 vs. 20.33, p = 0.02) There was a greater decay in acceleration over time for experts performing cardiac scans compared to novices (-0.194 vs. -0.050, p = 0.03) but not for abdominal scans or when measuring angular velocity. The frequency of movements (Hz) was higher for novices compared to experts for abdominal (16.68 vs. 13.79, p < 0.001) and cardiac (17.60 vs. 13.63, p = 0.002) scans. Discussion: This study supports the feasibility of a low-cost gyroscope and accelerometer integrated sensor to quantify the biomechanics of POCUS. It may also support the concept of "window shopping" as a method by which experts obtain abdominal and cardiac views, where sliding is used to find an acoustic window, then smaller rocking and tilting probe movements are used to refine the image.

Healthcare utilization and costs following non-fatal powdered and non-powdered firearm injuries for children and youth.

Little is known about the healthcare and economic burdens of non-fatal firearm injuries for children/youth beyond the initial admission. This study sought to estimate healthcare utilization and total direct healthcare costs of non-fatal powdered and non-powdered (air gun) firearm injuries 1-year post-injury. Using administrative data from 2003 to 2018 on all children/youth 0-24 years old in Ontario, Canada, a matched 1:2 cohort study was conducted to compare children/youth who experienced powdered and non-powdered firearm injuries with those who did not. Mean and median number of healthcare encounters and costs, and respective 95% confidence intervals (CIs) and interquartile ranges (IQRs), were estimated for both weapon type groups and controls and by intent. Children/youth who experienced a powdered and non-powdered firearm injury had a higher number of healthcare encounters and costs per year than those who did not. Mean 1-year costs for those with powdered and non-powdered firearm injuries were $8825 ($8007-$9643) and $2349 ($2118-$2578), respectively, versus $812 ($567-$1058) and $753 ($594-$911), respectively, for those without. Mean 1-year costs were highest for handgun injuries ($12,875 [95% CI $9941-$15,808]), and for intentional assault-related ($13,498 [$11,843-$15,153]; $3287 [$2213-$4362]), and intentional self-injuries ($14,773 [$6893-$22,652]; $6005 [$2193-$9817]) for both powdered and non-powdered firearm injuries, respectively.   Conclusion: Firearm injuries have substantial healthcare and economic burdens beyond the initial injury-related admission; this should be accounted for when examining the overall impact of firearm injuries. What is Known: • Child/youth firearm injuries have significant health and economic burdens. • However, existing work has mainly examined healthcare utilization and costs of initial admissions and/or have been limited to single-center studies and no studies have provide cost estimates by weapon type and intent. What is New: • Children/youth who suffered powdered firearm injuries had higher mean healthcare utilization and costs than those with non-powdered firearm injuries as well as comparable healthy children/youth. • Mean 1-year costs were highest for handgun injuries ($12,875), and for intentional assault-related ($13,498; $3287), and intentional self-injuries ($14,773; $6005) for powdered and non-powdered firearm injuries, respectively.

Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Update 2020.

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

Firearm injury epidemiology in children and youth in Ontario, Canada: a population-based study.

BACKGROUND AND OBJECTIVE: Despite firearms contributing to significant morbidity and mortality globally, firearm injury epidemiology is seldom described outside of the USA. We examined firearm injuries among youth in Canada, including weapon type, and intent. DESIGN: Population-based, pooled cross-sectional study using linked health administrative and demographic databases. SETTING: Ontario, Canada. PARTICIPANTS: All children and youth from birth to 24 years, residing in Ontario from 1 April 2003 to 31 March 2018. EXPOSURE: Firearm injury intent and weapon type using the International Classification of Disease-10 CM codes with Canadian enhancements. Secondary exposures were sociodemographics including age, sex, rurality and income. MAIN OUTCOMES: Any hospital or death record of a firearm injury with counts and rates of firearm injuries described overall and stratified by weapon type and injury intent. Multivariable Poisson regression stratified by injury intent was used to calculate rate ratios of firearm injuries by weapon type. RESULTS: Of 5486 children and youth with a firearm injury (annual rate: 8.8/100 000 population), 90.7% survived. Most injuries occurred in males (90.1%, 15.5/100 000 population). 62.3% (3416) of injuries were unintentional (5.5/100 000 population) of which 1.9% were deaths, whereas 26.5% (1452) were assault related (2.3/100 00 population) of which 18.7% were deaths. Self-injury accounted for 3.7% (204) of cases of which 72.0% were deaths. Across all intents, adjusted regression models showed males were at an increased risk of injury. Non-powdered firearms accounted for half (48.6%, 3.9/100 000 population) of all injuries. Compared with handguns, non-powdered firearms had a higher risk of causing unintentional injuries (adjusted rate ratio (aRR) 14.75, 95% CI 12.01 to 18.12) but not assault (aRR 0.84, 95% CI 0.70 to 1.00). CONCLUSIONS: Firearm injuries are a preventable public health problem among youth in Ontario, Canada. Unintentional injuries and those caused by non-powdered firearms were most common and assault and self-injury contributed to substantial firearm-related deaths and should be a focus of prevention efforts.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

BACKGROUND: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25619.

Comparison of Clerkship Directors' Expectations of Physical Examination Skills with Point-of-care Ultrasound Skills Using the RIME Framework.

Background: The expectations of point-of-care ultrasound (PoCUS) in undergraduate clerkship at the University of Ottawa has not been described. We compared clerkship directors' expectations of physical examination skills with PoCUS skills, before and after completing the clerkship rotation. Methods: A pilot-tested, expert developed, bilingual on-line survey consisting of 15 questions was sent to all clerkship directors (23) in December 2019. The survey included questions regarding the expectations of medical students with respect to physical examination and PoCUS using the RIME Framework: none, reporter, interpreter, manager, educator. Results: The response rate was 60.9% (14/23). With regards to physical exam skills, 82.8% of directors had no expectations or expected students to be reporters when starting clerkship. At graduation, 77.5% of directors expected students to be interpreters, managers, or educators. For PoCUS, 100.0% of directors had no expectations or expected students to be reporters when starting clerkship. At clerkship completion, 33.0% of directors felt that students should be interpreters or managers for PoCUS skills. Conclusions: Clerkship directors have low expectations of PoCUS skills for entering and graduating clerks when compared with their physical examination skills despite formal pre-clerkship PoCUS objectives. Enhanced communication and targeted education of directors could improve the PoCUS curriculum.

Dissecting the Contemporary Clerkship: Theory-based Educational Trial of Videos Versus Lectures in Medical Student Education.

BACKGROUND: Despite increasing use of the flipped classroom (FC) technique in undergraduate medical education, the benefit in learning outcomes over lectures is inconsistent. Best practices in preclass video design principles are rarely used, and it is unclear if videos can replace lectures in contemporary medical education. METHODS: We conducted a prospective quasi-experimental controlled educational study comparing theory-based videos to traditional lectures in a medical student curriculum. Medical students enrolled in an emergency medicine clerkship were randomly assigned to either a lecture group (LG) or a video group (VG). The slide content was identical, and the videos aligned with cognitive load theory-based multimedia design principles. Students underwent baseline (pretest), week 1 (posttest), and end-of-rotation (retention) written knowledge tests and an observed structured clinical examination (OSCE) assessment. We compared scores between both groups and surveyed student attitudes and satisfaction with respect to the two learning methods. RESULTS: There were 104 students who participated in OSCE assessments (49 LG, 55 VG) and 101 students who participated in knowledge tests (48 LG, 53 VG). The difference in OSCE scores was statistically significant 1.29 (95% confidence interval = 0.23 to 2.35, t(102) = 2.43, p = 0.017), but the actual score difference was small from an educational standpoint (12.61 for LG, 11.32 for VG). All three knowledge test scores for both groups were not significantly different. CONCLUSIONS: Videos based on cognitive load theory produced similar results and could replace traditional lectures for medical students. Educators contemplating a FC approach should devote their valuable classroom time to active learning methods.

Health human resources for emergency medicine: a framework for the future.

In June of 2016, the Collaborative Working Group (CWG) on the Future of Emergency Medicine presented its final report at the Canadian Association of Emergency Physicians (CAEP) annual meeting in Quebec City. The CWG report made a number of recommendations concerning physician Human Health Resource (HHR) shortfalls in emergency medicine, specific changes for both the Royal College of Physicians and Surgeons of Canada (FRCPC) and the College of Family Physicians of Canada (CCFP-EM) training programs, HHR needs in rural and remote hospitals, future collaboration of the CCFP-EM and FRCPC programs, and directions for future research. All recommendations were endorsed by CAEP, the Royal College of Physicians and Surgeons of Canada (RCPSC), and the College of Family Physicians of Canada (CFPC). The CWG report was published in CJEM and has served as a basis for ongoing discussion in the emergency medicine community in Canada. The CWG identified an estimated shortfall of 478 emergency physicians in Canada in 2016, rising to 1071 by 2020 and 1518 by 2025 assuming no expansion of EM residency training capacity. In 2017, the CAEP board struck a new committee, The Future of Emergency Medicine in Canada (FEMC), to advocate with appropriate stakeholders to implement the CWG recommendations and to continue with this important work. FEMC led a workshop at CAEP 2018 in Calgary to develop a regional approach to HHR advocacy, recognizing different realities in each province and region. There was wide representation at this workshop and a rich and passionate discussion among those present. This paper represents the output of the workshop and will guide subsequent deliberations by FEMC. FEMC has set the following three goals as we work toward the overarching purpose to improve timely access to high quality emergency care: (1) to define and describe categories of emergency departments (EDs) in Canada, (2) define the full time equivalents required by category of ED in Canada, and (3) recommend the ideal combination of training and certification for emergency physicians in Canada. A fourth goal supports the other three goals: (4) urge further consideration and implementation of the CWG-EM recommendations related to coordination and optimization of the current two training programs. We believe that goals 1 and 2 can largely be accomplished by the CAEP annual meeting in 2020, and goal 3 by the CAEP annual meeting in 2021. Goal 4 is ongoing with both the RCPSC and the CFPC. We urge the EM community across Canada to engage with our committee to support improved access and EM care for all Canadians.

Canadian stroke best practice recommendations: Secondary prevention of stroke, sixth edition practice guidelines, update 2017.

The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.