Identifying the exceptional learner in medical education: A doing vs. being framework.

PURPOSE: This study aims to understand what is known about the high performing or exceptional learner in medical education. There is a rich literature about learners in difficulty, yet little is known about those performing at the high end, also known as exceptional learners. METHODS: A qualitative study was undertaken whereby 15 faculty members at the University of Toronto were interviewed to explore their experiences with these learners. RESULTS: Based on the findings, we developed a framework to categorize characteristics of exceptional learners by differentiating them as either 'Being' (a pre-existing attribute or set of values that the learner possesses from the start of training) or 'Doing' (demonstrable characteristics that can be observed or measured). Using this framework, we identified five characteristics in the category of 'Being', five in the category of 'Doing', and two that could be situated in either or both. CONCLUSION: Utilizing this framework to describe exceptional learners will aid teachers in identifying them early in their training so that their training experience can be enhanced. This novel approach contributes to our knowledge of the exceptional medical learner. The optimization of the training experience will maximize the opportunity to ensure that these learners reach their full potential to contribute to the healthcare system.

Impact of early waves of the COVID-19 pandemic on family medicine residency training: Analysis of survey data.

OBJECTIVE: To identify how graduating and incoming family medicine residents (FMR) experienced changes to their education during the early waves of the COVID-19 pandemic. DESIGN: The Family Medicine Longitudinal Survey was modified with questions related to the impact of COVID-19 on FMR and their training. Short-answer responses underwent thematic analysis. Responses to Likert scale and multiple-choice questions were reported as summary statistics. SETTING: Department of Family and Community Medicine at the University of Toronto in Ontario. PARTICIPANTS: Graduating FMR in spring 2020 and incoming FMR in fall 2020. MAIN OUTCOME MEASURES: Residents' perceptions of the impact of COVID-19 on clinical skills acquisition and preparedness for practice. RESULTS: Surveys response rates were 124 of 167 (74%) and 142 of 162 (88%) for graduating and incoming residents, respectively. Important themes for both cohorts included reduced access to clinical environments, reduced patient volumes, and lack of exposure to procedural skills. While the graduating cohort indicated they felt confident to begin practising family medicine, they described being impacted by the loss of a tailored learning environment, including canceled or altered electives. In contrast, incoming residents reported the loss of core skills, such as physical examination competency, as well as the loss of face-to-face communication, rapport, and relationship-building opportunities. However, both cohorts endorsed gaining new skills during the pandemic, including conducting telemedicine appointments, pandemic planning, and interfacing with public health. CONCLUSION: Based on these results, residency programs can specifically tailor solutions and modifications to address common themes across cohorts to facilitate optimal learning environments in pandemic times.

COVID-19: A Qualitative Analysis of Academic Family Physician Leaders' Crisis Response.

BACKGROUND AND OBJECTIVES: The onset of the COVID-19 pandemic severely threatened all aspects of academic family medicine, constituting a crisis. Multiple publications have identified recommendations and documented the creative responses of primary care and academic organizations to address these challenges, but there is little research on how decisions came about. Our objective was to gain insight into the context, process, and nature of family medicine leaders' discussions in pivoting to address a crisis. METHODS: We used a qualitative descriptive design to explore new dimensions of existing concepts. The setting was the academic family medicine department at the University of Toronto. To identify leadership themes, we used the constant comparative method to analyze transcripts of monthly meetings of the departmental executive: three meetings immediately before and three following the declaration of a state emergency in Ontario. RESULTS: Six themes were evident before and after the onset of the pandemic: building capacity in academic family medicine; developing leadership; advancing equity, diversity, and inclusion; learner safety and wellness; striving for excellence; and promoting a supportive and collegial environment. Five themes emerged as specific responses to the crisis: situational awareness; increased multidirectional communication; emotional awareness; innovation in education and patient care; and proactive planning for extended adaptation to the pandemic. CONCLUSION: Existing cultural and organizational approaches formed the foundation for the crisis response, while crisis-specific themes reflected skills and attitudes that are essential in clinical family medicine, including adapting to community needs, communication, and emotional awareness.

Impact of interactive multi-media learning for physicians in musculoskeletal education - a pilot study.

BACKGROUND: The aim of this educational study was to investigate the use of interactive case-based modules relating to the screening and identification of early-stage inflammatory arthritis in both online technology (OLT) and paper (PF) formats with identical content. METHODS: Forty learners from family medicine or rheumatology residency programs were recruited. Content pertaining to a "Sore Hands, Sore Feet" (SHSF) and Gait Arms Legs Spine (GALS) screening tool modules were selected, reviewed and developed based on a validated curriculum from the World Health Organization and Canadian Curriculum for MSK conditions. Both the SHSF module and GALS screening tool were assessed via a randomized control trial. Assessments were completed during an orientation with all learners; then prior to the intervention (T1); at the end of the module (T2) and 3 months following the modules (T3) to assess retention. Focus groups were conducted to determine learners' satisfaction with the different learning formats. Baseline data was collated, and analysis performed after randomization into the PF (control) and OLT (experimental) groups. Repeated measures ANOVA was used for statistical analyses. RESULTS: Forty participants were recruited and randomized into the PF or OLT group (n = 20 each). At 3 months, there were n = 31 participants for SHSF (PF n = 19, OLT n = 12) and n = 32 for GALS (PF n = 19, OLT n = 13). There was no significant difference between the OLT and PF groups in both analyses. A significant increase in scores from Pre- to Post-Module in SHSF (F (1, 18) = 24.62. p < .0001) and GALS (F (1, 30) = 40.08, p < .0001) were identified to suggest learning occurred with both formats. The repeated measures ANOVA to assess retention revealed a significant decrease in scores from Post-Module to Follow-up for both learning format groups for SHSF (F (1, 29) = 4.68. p = .039), and GALS (F (1, 30) = 18.27. p < .0001) suggesting 3 months may be too long to retain this educational information. CONCLUSIONS: Both formats led to residents' ability to screen, identify and initially manage inflammatory arthritis. The hypothesis is rejected because both OLT and PF groups demonstrated significant learning during the process regardless of format. It is important to emphasize that from T1 (pre-module) to T2 (post-module), the residents demonstrated learning regardless of group to which they were assigned. However, learning retention declined from T2 (post-module) to T3 (three-month follow-up). Regular review of knowledge may be required earlier than 3 months to retain information learned. This study may impact educational strategies in MSK health. TRIAL REGISTRATION: This study did not involve "patients" rather learners and as such it was not registered.

The system, the resident, and the preceptor: a curricular approach to continuity of care training.

BACKGROUND: Continuity of care (CoC) is integral to the practice of comprehensive primary care, yet research in the area of CoC training in residency programs is limited. In light of distributed medical education and evolving accreditation standards, a rigorous understanding of the context and enablers contributing to CoC education must be considered in the design and delivery of residency training programs. APPROACH: At our preceptor-based community academic site, we developed a system-resident-preceptor (SRP) framework to explore factors that influence a resident's perception regarding CoC, and established variables in each area to enhance learning. We then implemented a two-year educational SRP intervention (SRPI) to one cohort of residents and their preceptors to integrate critical education factors and align teaching of continuity of care within curricular goals. EVALUATION: Evaluation of the intervention was based on resident interviews and faculty focus groups, and a qualitative phenomenological approach was used to analyze the data. While some factors identified are inherent to family medicine, the opportunity for reflection is a unique component to inculcate CoC learning. REFLECTION: The SRP innovation provides a unique framework to facilitate residents' understanding and development of CoC competency. Our model can be applied to all residency programs, including traditional academic sites as well as distributed training sites, to enhance CoC education.

Developmental Evaluation: six ways to get a grip on the potential of education scholarship to serve innovation.

In March 2020, COVID-19 challenged health and educational systems across the country. The rapid reallocation of resources to ensure public safety had taken priority over educational obligations. Healthcare students were removed from clinical environments as their learning came to a grinding halt. While academic institutions were pivoting and transforming teaching and learning experiences, students responded to the pandemic with innovation, attending to gaps in patient care. As educators, we must understand how we can further support students and faculty to unleash innovative thinking during a crisis. To begin to address this educational need, academic institutions now have an opportunity to broaden the practice of education scholarship in accordance with best practices to nurture innovation and innovative thinking. What framework can aid us in this endeavor? In times of instability, Developmental Evaluation is an approach that can support the implementation of innovations within medical education. Using an example of an innovation in medical education, we offer six practical tips to begin to use Developmental Evaluation to support and enable learners and faculty in the creation of innovations and contribute to a broader definition of education scholarship.

En mars 2020, la COVID-19 a bouleversé les systèmes de santé et d'éducation de tout le pays. La réaffectation rapide des ressources pour assurer la sécurité du public avait pris le pas sur les obligations éducatives. Les étudiants en santé ont été retirés des environnements cliniques et leur apprentissage a connu un arrêt net. Les établissements universitaires ont introduit des ajustements qui ont transformé les expériences d'enseignement et d'apprentissage. De leur côté, réagissant à la pandémie de manière innovante, les étudiants sont intervenus pour combler les besoins en soins aux patients. Il serait pertinent pour nous, éducateurs, de trouver les façons de mieux aider les étudiants et le corps enseignant à laisser libre cours à leur originalité dans les situations de crise. En vue de répondre à ce besoin éducatif, les établissements universitaires ont l'occasion d'aligner la recherche en éducation sur les meilleures pratiques pour favoriser l'innovation et la pensée novatrice. Quel cadre adopter pour nous aider dans cette entreprise? L'évaluation évolutive fait partie des approches qui peuvent soutenir la mise en œuvre d'innovations dans l'éducation médicale en période d'instabilité. À l'aide d'un exemple d'innovation dans le domaine, nous proposons six conseils pratiques pour faire de l'évaluation évolutive un facilitateur de l'innovation par les apprenants et les enseignants et un levier pour élargir la portée de la recherche en éducation.

A Master Class in Family Doctor Leadership: Evaluating an Innovative Program.

BACKGROUND AND OBJECTIVES: In family medicine, leadership is critical for health care delivery, advancing curricula, research, and quality improvement. Systematic reviews of leadership development programs in health care identify limitations, calling for innovative designs and rigorous assessment. Our objective was to evaluate the impact of applying master class principles to leadership development in academic family medicine. METHODS: We used mixed methods to assess the impact of an innovative master class program on 15 emerging leaders in a large academic department of family medicine. The program consisted of five sessions where family physician masters shared their wisdom, techniques, and feedback with promising leaders. Quantitative evaluation involved participants' ratings of each session's content and delivery using a 5-point Likert scale. We assessed postcourse semistructured interviews with participants qualitatively using descriptive thematic content analysis. RESULTS: Individual sessions were highly evaluated, with a combined mean of 4.82/5. Qualitative thematic analysis identified self-perceived increased effectiveness in leadership activities; increased confidence as a leader; increased motivation to be a leader; and perceptions of value from the program, contributing to what participants described as unexpected potential change within themselves. Themes related to effectiveness of the program were practical advice; networking; diverse topics; accessible speakers sharing personal stories; and small-group, informal, early-evening format. CONCLUSIONS: Master class concepts can be adapted to leadership development in academic family medicine, with evidence of early positive impact on participants' self-perception of leadership skills and confidence. Further research is warranted to assess organizational impact and applicability to other settings.

The Basic Science of Patient-Physician Communication: A Critical Scoping Review.

PURPOSE: Strong verbal communication skills are essential for physicians. Despite a wealth of medical education research exploring communication skills training, learners struggle to become strong communicators. Integrating basic science into the curriculum provides students with conceptual knowledge that improves learning outcomes and facilitates the development of adaptive expertise, but the conceptual knowledge, or "basic science," of patient-provider communication is currently unknown. This review sought to address that gap and identify conceptual knowledge that would support improved communication skills training for medical trainees. METHOD: Combining the search methodology of Arksey and O'Malley with a critical analytical lens, the authors conducted a critical scoping review of literature in linguistics, cognitive psychology, and communications to determine: what is known about verbal communication at the level of word choice in physician-patient interactions? Studies were independently screened by 3 researchers during 2 rounds of review. Data extraction focused on theoretical contributions associated with language use and variation. Analysis linked patterns of language use to broader theoretical constructs across disciplines. RESULTS: The initial search returned 15,851 unique studies, and 271 studies were included in the review. The dominant conceptual groupings reflected in the results were: (1) clear and explicit language, (2) patient participation and activation, (3) negotiating epistemic knowledge, (4) affiliative language and emotional bonds, (5) role and identity, and (6) managing transactional and relational goals. CONCLUSIONS: This in-depth exploration supports and contextualizes theory-driven research of physician-patient communication. The findings may be used to support future communications research in this field and educational innovations based on a solid theoretical foundation.

Assessing undergraduate medical education through a generalist lens.

PROBLEM BEING ADDRESSED: Medical schools aim to integrate the values of generalism into their undergraduate programs. However, currently no program has been described to measure the degree to which formal curricular materials represent generalist principles. OBJECTIVE OF PROGRAM: To quantify the generalism principles present in undergraduate medical education learning materials and to provide recommendations to enhance generalism content. PROGRAM DESCRIPTION: A review of the literature and accreditation documents was conducted to identify key elements of medical generalism. An evidence-informed tool, the Toronto Generalism Assessment Tool, was developed and applied to the new preclerkship undergraduate cases at the University of Toronto in Ontario. The findings regarding the presence of generalism principles and recommendations to enhance generalism content were provided to case developers. The recommendations were valued and were incorporated into subsequent iterations of the cases. CONCLUSION: This is the first report of a successful evidence-informed program to assess the degree of generalism reflected in undergraduate medical education curricular documents. This program can be used by other institutions wishing to review their curricula through a generalist lens.

Family Medicine Journal Club: To Tweet or Not to Tweet?

BACKGROUND AND OBJECTIVES: Online journal clubs have recently become popular, but their effectiveness in promoting meaningful discussion of the evidence is unknown. We aimed to understand the learner experience of a hybrid online-traditional family medicine journal club. METHODS: We used a qualitative descriptive study to understand the experience of medical students and residents at the University of Toronto with the hybrid online-traditional family medicine journal club, including perceived useful and challenging aspects related to participant engagement and fostering discussion. The program, informed by the literature and needs assessment, comprised five sessions over a 6-month period. Learners led the discussion between the distributed sites via videoconferencing and Twitter. Six of 12 medical students and 33 of 57 residents participated in one of four focus groups. Thematic data analysis was performed using the constant comparison method. RESULTS: While participants could appreciate the potential of an online component to journal club to connect distributed learners, overall, they preferred the small group, face-to-face format that they felt produced richer and more meaningful discussion, higher levels of engagement, and a better learning opportunity. Videoconferencing and Twitter were seen as diminishing rather than enhancing their learning experience and they challenged the assumption that millennials would favor the use of social media for learning. CONCLUSIONS: Our study demonstrates that for discussion-based teaching activities such as journal club, learners prefer a small-group, face-to-face format. Our findings have implications for the design of curricular programs for distributed medical learners.

Gender Effects in Assessment of Clinical Teaching: Does Concordance Matter?

BACKGROUND: Gender bias is thought to exist in the assessment of clinical teachers, yet its extent in different specialties is not well-documented nor has it been studied at the individual-dyadic level. OBJECTIVE: The authors sought to determine whether gender bias exists in residents' assessments of faculty teaching in 3 clinical departments, and if present, whether this is influenced by gender concordance or discordance between the faculty and resident. METHODS: Residents' ratings of faculty in internal medicine (800 faculty, 5753 ratings), surgery (377, 2249), and family medicine (672, 3438) at the University of Toronto from 2016-2017 were analyzed using the overall global rating on a 5-point scale. A mixed-effects linear regression analysis accounted for nesting of ratings within each faculty member. RESULTS: Overall scores of teaching effectiveness showed a strong skew to favorable ratings for all faculty and a ceiling effect. However, gender effects differed across departments. In internal medicine (38.5% female faculty), no significant gender effects were detected. In surgery (16.2% female) and family medicine (53.0% female), male faculty received significantly higher scores than female faculty. In surgery this was driven by male residents giving male faculty higher ratings (4.46 vs 4.26, P < .001). In family medicine this was driven by male faculty receiving higher ratings regardless of resident gender (4.65 to 4.57, P < .001). CONCLUSIONS: Although effects were very small and inconsistent, with gender concordance mattering only for one department, it suggests that gender is a meaningful source of variance in teaching assessments.

The state-of-play in physician health systems leadership research.

PURPOSE: This paper aims to review a decade of evidence on physician participation in health system leadership with the view to better understand the current state of scholarship on physician leadership activity in health systems. This includes examining the available evidence on both physicians' experiences of health systems leadership (HSL) and the impact of physician leadership on health system reform. DESIGN/METHODOLOGY/APPROACH: A state-of-the-art review of studies (between 2007 and 2017); 51 papers were identified, analyzed thematically and synthesized narratively. FINDINGS: Six main themes were identified in the literature as follows: (De)motivation for leadership, leadership readiness and career development, work demands and rewards, identity matters: acceptance of self (and other) as leader, leadership processes and relationships across health systems and leadership in relation to health system outcomes. There were seemingly contradictory findings across some studies, pointing to the influence of regional and cultural contextual variation on leadership practices as well entrenched paradoxical tensions in health system organizations. RESEARCH LIMITATIONS/IMPLICATIONS: Future research should examine the influence of varying structural and psychological empowerment on physician leadership practices. Empirical attention to paradoxical tensions (e.g. between empowerment and control) in HSL is needed, with specific attention to questions on how such tensions influence leaders' decision-making about system reform. ORIGINALITY/VALUE: This review provides a broad synthesis of diverse papers about physician participation in health system leadership. Thus, it offers a comprehensive empirical synthesis of contemporary concerns and identifies important avenues for future research.

Is postgraduate leadership education a match for the wicked problems of health systems leadership? A critical systematic review.

PURPOSE: There have been a growing number of leadership education programs for physicians. However, debates about the value and efficacy of leadership education in medicine persist, and there are calls for systematic and critical perspectives on medical leadership development. Here, we review evidence on postgraduate leadership education and discuss findings in relation to contemporary evidence on leadership education and practice. METHOD: We searched multiple databases for papers on postgraduate leadership development programs, published in English between 2007 and 2017. We identified 4,691 papers; 31 papers met the full inclusion criteria. Data regarding curricular content and design, learner demographics, instructional methods, and learning outcomes were abstracted and synthesized. RESULTS: There was modest evidence for effectiveness of programs in influencing knowledge and skills gains in select domains. However, the conceptual underpinnings of the 'leadership' training delivered were often unclear. Contemporary theory and evidence on leadership practice was not widely incorporated in program design. Programs were almost exclusively uni-professional, focused on discrete skill development, and did not address systems-level leadership issues. Broader leadership capacity building strategies were underutilized. A new wave of longitudinal, integrated clinical and leadership programming is observed. CONCLUSIONS: Our findings raise questions about persistent preparation-practice gaps in leadership education in medicine. Leadership education needs to evolve to incorporate broader collective capacity building, as well as evidence-informed strategies for leadership development. Barriers to educational reform need to be identified and addressed as educators work to re-orientate education programs to better prepare budding physician leaders for the challenges of health system leadership.