The PARTNER trial of neoadjuvant olaparib with chemotherapy in triple-negative breast cancer.

PARTNER is a prospective, phase II-III, randomized controlled clinical trial that recruited patients with triple-negative breast cancer1,2, who were germline BRCA1 and BRCA2 wild type3. Here we report the results of the trial. Patients (n = 559) were randomized on a 1:1 basis to receive neoadjuvant carboplatin-paclitaxel with or without 150 mg olaparib twice daily, on days 3 to 14, of each of four cycles (gap schedule olaparib, research arm) followed by three cycles of anthracycline-based chemotherapy before surgery. The primary end point was pathologic complete response (pCR)4, and secondary end points included event-free survival (EFS) and overall survival (OS)5. pCR was achieved in 51% of patients in the research arm and 52% in the control arm (P = 0.753). Estimated EFS at 36 months in the research and control arms was 80% and 79% (log-rank P > 0.9), respectively; OS was 90% and 87.2% (log-rank P = 0.8), respectively. In patients with pCR, estimated EFS at 36 months was 90%, and in those with non-pCR it was 70% (log-rank P < 0.001), and OS was 96% and 83% (log-rank P < 0.001), respectively. Neoadjuvant olaparib did not improve pCR rates, EFS or OS when added to carboplatin-paclitaxel and anthracycline-based chemotherapy in patients with triple-negative breast cancer who were germline BRCA1 and BRCA2 wild type. ClinicalTrials.gov ID: NCT03150576 .

Integration of Patient-reported Outcome Measures in Pediatric Hematology: A Qualitative Methods Study.

Patient-reported outcome measures (PROMs) are self-reported questionnaires that allow patients and families to evaluate health-related experiences without influence or oversight from health care professionals. This study aimed to rate the relevance of existing PROMs for pediatric hematology patients, as identified by a recent systematic review, as well as to evaluate the receptivity of electronic PROM integration into clinical practice. Focus groups and interviews were conducted with children (10) and parents (19) impacted by nonmalignant hematological disorders, as well as with health care professionals (6). We observed strong support for the TranQol in thalassemia (100% for both parents [P] and children [C]); the Canadian Haemophilia Outcomes-Kids' Life Assessment Tool (CHO-KLAT) (100% P, 75% C) and Haemophilia Quality of Life questionnaire (Haemo-QoL) (100% P and C) in hemophilia; the Pediatric Quality of Life Inventory (PedsQL) Sickle Cell Module (75% P, 100% C); and the Kids ITP Tool in immune thrombocytopenia (100% P, 66.7% C). Generic tools such as the PedsQL Generic were met with mixed support. Electronic PROM integration received universal support. We obtained strong support for the integration of a web-based platform into clinical practice and a preference for disease-specific PROMs over generic PROMs. Future projects may explore the development of a child-friendly Canadian web-based platform to standardize quality-of-life evaluation within the clinical encounter.

When is a person dead? The Canadian public's understanding of death and death determination: a nationwide survey.

PURPOSE: We aimed to describe the Canadian public's understanding and perception of how death is determined in Canada, their level of interest in learning about death and death determination, and their preferred strategies for informing the public. METHODS: We conducted a nationwide cross-sectional survey of a representative sample of the Canadian public. The survey presented two scenarios of a man who met current criteria for neurologic death determination (scenario 1) and a man who met current criteria for circulatory death determination (scenario 2). Survey questions evaluated understanding of how death is determined, acceptance of death determination by neurologic and circulatory criteria, and interest and preferred strategies in learning more about the topic. RESULTS: Among 2,000 respondents (50.8% women; n = 1,015), nearly 67.2% believed that the man in scenario 1 was dead (n = 1,344) and 81.2% (n = 1,623) believed that the man in scenario 2 was dead. Respondents who believed that the man was not dead or were unsure endorsed several factors that may increase their agreement with the determination of death, including requiring more information about how death was determined, seeing the results of brain imaging/tests, and a third doctor's opinion. Predictors of disbelief that the man in scenario 1 is dead were younger age, being uncomfortable with the topic of death, and subscribing to a religion. Predictors of disbelief that the man in scenario 2 is dead were younger age, residing in Quebec (compared with Ontario), having a high school education, and subscribing to a religion. Most respondents (63.3%) indicated interest in learning more about death and death determination. Most respondents preferred to receive information about death and death determination from their health care professional (50.9%) and written information provided by their health care professional (42.7%). CONCLUSION: Among the Canadian public, the understanding of neurologic and circulatory death determination is variable. More uncertainty exists with death determination by neurologic criteria than with circulatory criteria. Nevertheless, there is a high level of general interest in learning more about how death is determined in Canada. These findings provide important opportunities for further public engagement.

RéSUME: OBJECTIF: Notre objectif était de décrire la compréhension et la perception du public canadien quant à la façon dont le décès est déterminé au Canada, son niveau d'intérêt à en apprendre davantage sur le décès et la détermination du décès, et ses stratégies préférées pour informer le public. MéTHODE: Nous avons réalisé un sondage transversal national auprès d'un échantillon représentatif de la population canadienne. L'enquête a présenté deux scénarios : un homme qui répondait aux critères actuels de détermination d'un décès neurologique (scénario 1) et un homme qui répondait aux critères actuels de détermination d'un décès cardiocirculatoire (scénario 2). Les questions de l'enquête évaluaient la compréhension de la façon dont le décès est déterminé, l'acceptation de la détermination du décès selon des critères neurologiques et circulatoires, et l'intérêt et les stratégies préférées pour en apprendre davantage sur le sujet. RéSULTATS: Parmi les 2000 répondants (50,8 % de femmes; n = 1015), près de 67,2 % ont estimé que l'homme du scénario 1 était décédé (n = 1344) et 81,2 % (n = 1623) ont estimé que l'homme du scénario 2 était décédé. Les répondants qui croyaient que l'homme n'était pas décédé ou qui n'étaient pas sûrs ont acquiescé à plusieurs facteurs qui pourraient accroître leur accord avec la détermination du décès, y compris le besoin de plus de renseignements sur la façon dont le décès a été déterminé, la consultation des résultats d'imagerie et des tests cérébraux et l'opinion d'un troisième médecin. Les prédicteurs de non-conviction que l'homme dans le scénario 1 était décédé étaient le fait d'être plus jeune, le fait d'être mal à l'aise avec le sujet de la mort et la croyance en une religion. Les prédicteurs de non-conviction à l'égard du décès de l'homme dans le scénario 2 étaient le fait d'être plus jeune, d'être résident du Québec (comparativement à l'Ontario), d'avoir complété des études secondaires et la croyance en une religion. La plupart des répondants (63,3 %) ont indiqué qu'ils souhaiteraient en apprendre davantage sur le décès et la détermination du décès. La plupart des répondants préféraient recevoir de l'information sur le décès et la détermination du décès de leur professionnel de la santé (50,9 %) et de l'information écrite fournie par leur professionnel de la santé (42,7 %). CONCLUSION: Parmi le public canadien, la compréhension de la détermination du décès neurologique et cardiocirculatoire est variable. Il existe plus d'incertitude en matière de détermination du décès selon des critères neurologiques que selon des critères cardiocirculatoires. Néanmoins, il existe un grand intérêt général à en apprendre davantage sur la façon dont le décès est déterminé au Canada. Ces résultats offrent d'importantes possibilités de participation accrue du public à l'avenir.

Death determination by neurologic criteria-what do families understand?

PURPOSE: Currently, there is little empirical data on family understanding about brain death and death determination. The purpose of this study was to describe family members' (FMs') understanding of brain death and the process of determining death in the context of organ donation in Canadian intensive care units (ICUs). METHODS: We conducted a qualitative study using semistructured, in-depth interviews with FMs who were asked to make an organ donation decision on behalf of adult or pediatric patients with death determination by neurologic criteria (DNC) in Canadian ICUs. RESULTS: From interviews with 179 FMs, six main themes emerged: 1) state of mind, 2) communication, 3) DNC may be counterintuitive, 4) preparation for the DNC clinical assessment, 5) DNC clinical assessment, and 6) time of death. Recommendations on how clinicians can help FMs to understand and accept DNC through communication at key moments were described including preparing FMs for death determination, allowing FMs to be present, and explaining the legal time of death, combined with multimodal strategies. For many FMs, understanding of DNC unfolded over time, facilitated with repeated encounters and explanation, rather than during a single meeting. CONCLUSION: Family members' understanding of brain death and death determination represented a journey that they reported in sequential meeting with health care providers, most notably physicians. Modifiable factors to improve communication and bereavement outcomes during DNC include attention to the state of mind of the family, pacing and repeating discussions according to families' expressed understanding, and preparing and inviting families to be present for the clinical determination including apnea testing. We have provided family-generated recommendations that are pragmatic and can be easily implemented.

RéSUMé: OBJECTIF: À l'heure actuelle, il y a peu de données empiriques sur la compréhension des familles de la mort cérébrale et de la détermination du décès. Le but de cette étude était de décrire la compréhension des membres de la famille de la mort cérébrale et du processus de détermination du décès dans le contexte du don d'organes dans les unités de soins intensifs (USI) canadiennes. MéTHODE: Nous avons mené une étude qualitative à l'aide d'entrevues semi-structurées et approfondies avec des membres de la famille à qui on a demandé de prendre une décision de don d'organes au nom de patients adultes ou pédiatriques dont le décès avait été déterminé selon des critères neurologiques (DCN) dans les unités de soins intensifs canadiennes. RéSULTATS: Sur la base d'entrevues avec 179 membres de la famille, six thèmes principaux ont émergé : 1) l'état d'esprit, 2) la communication, 3) le DCN peut être contre-intuitif, 4) la préparation à l'évaluation clinique pour un DCN, 5) l'évaluation clinique pour un DCN et 6) le moment du décès. Des recommandations sur la façon dont les cliniciens peuvent aider les membres de la famille à comprendre et à accepter un DCN par la communication à des moments clés ont été décrites, y compris la préparation des membres de la famille à la détermination du décès, l'autorisation de la présence des membres de la famille et l'explication de l'heure légale du décès, combinées à des stratégies multimodales. Pour de nombreux membres de la famille, la compréhension du DCN s'est développée au fil du temps et a été facilitée par des rencontres et des explications répétées plutôt qu'au cours d'une seule rencontre. CONCLUSION: La compréhension qu'ont les membres de la famille de la mort cérébrale et de la détermination du décès représente un parcours qu'ils ont décrit lors de rencontres successives avec des acteurs de soins de santé, et particulièrement avec des médecins. Les facteurs modifiables pour améliorer la communication et les issues du deuil pendant un DCN comprennent l'attention portée à l'état d'esprit de la famille, le rythme et la répétition des discussions en fonction de la compréhension exprimée par les familles, ainsi que la préparation et l'invitation des familles à être présentes pour la détermination clinique, y compris pendant le test d'apnée. Nous avons fourni des recommandations familiales qui sont pragmatiques et peuvent être facilement mises en œuvre.

A pediatric virtual care evaluation framework and its evolution using consensus methods.

BACKGROUND: The use of virtual care has increased dramatically in response to the COVID-19 pandemic, yet evidence is lacking regarding the impact of virtual care on patient outcomes, particularly in pediatrics. A standardized evaluation approach is required to support the integration of virtual care into pediatric health care delivery programs. The objective of this work was to develop a comprehensive and structured framework for pediatric virtual care evaluation. This framework is intended to engage and guide care providers, health centres, and stakeholders towards the development of a standardized approach to the evaluation of pediatric virtual care. METHODS: We brought together a diverse multidisciplinary team, including pediatric clinicians, researchers, digital health leads and analysts, program leaders, a human factors engineer, a family advisor and our manager of health equity and diversity. The team reviewed the literature, including published evaluation frameworks, and used a consensus-based method to develop a virtual care evaluation framework applicable to a broad spectrum of pediatric virtual care programs. We used an iterative process to develop framework components, including domains and sub-domains, examples of evaluation questions, measures, and data sources. Team members met repeatedly over seven months to generate and provide feedback on all components of the framework, making revision as needed until consensus was reached. The framework was then applied to an existing virtual care program. RESULTS: The resulting framework includes four domains (health outcomes, health delivery, individual experience, and program implementation) and 19 sub-domains designed to support the development and evaluation of pediatric virtual care programs. We also developed guidance on how to use the framework and illustrate its utility by applying it to an existing pediatric virtual care program. CONCLUSIONS: This virtual care evaluation framework expands on previously developed frameworks by providing additional detail and a structure that supports practical application. It can be used to evaluate a wide range of pediatric virtual care programs in a standardized manner. Use of this comprehensive yet easy to use evaluation framework will inform appropriate implementation and integration of virtual care into routine practice and support its sustainability and continuous improvement.

Including patients and caregivers in assessment in the pediatric competence by design curriculum: A national consensus study.

Although evidence supports diverse assessment strategies, including patient/caregiver involvement in Competency-Based Medical Education (CBME), few residency programs formally include patients/caregivers in assessment. We aimed to determine the milestones for which patient/caregiver inclusion would be valuable in the Canadian Pediatric Competence By Design (CBD) curriculum.Program directors from 17 Canadian pediatric residency programs were invited to participate in a Delphi study. This Delphi included 209 milestones selected by the study team from the 320 milestones of the draft pediatric CBD curriculum available at the time of the study. In round 1, 16 participants representing 13 institutions rated the value of including patients/caregivers in the assessment of each milestone using a 4-point scale. We obtained consensus for 150 milestones, leaving 59 for re-exposure. In round 2, 14/16 participants rated remaining items without consensus. Overall, 67 milestones met consensus for 'valuable,' of which 11 met consensus for 'extremely valuable.' The majority of these milestones related to communication skills.Patient/caregiver assessment is valuable for 21% of milestones in the draft pediatric CBD curriculum, predominantly those relating to communication skills. This confirms the perceived importance of patient/caregiver assessment of trainees in CBME curricula; formal inclusion may be considered. Future directions could include exploring patients/caregivers' perspectives of their roles in assessment in CBD.

The experiences of family members of deceased organ donors and suggestions to improve the donation process: a qualitative study.

BACKGROUND: Decisions about organ donation are stressful for family members of potential organ donors. We sought to comprehensively explore the donation process from interviews conducted with family members of patients admitted to pediatric and adult intensive care units in Canada. METHODS: We conducted a qualitative study using semistructured, in-depth interviews with 271 family members asked to make an organ donation decision. We recruited participants from all provinces with an organ donation organization (n = 10), and analyzed themes using a modified grounded theory approach. On the basis of these interviews, suggestions were made by researchers and family members on how to improve the process of organ donation. RESULTS: We identified 3 main themes and 9 subthemes. Families need more comprehensive support around the time of donation, including having access to someone with shared experiences, support during specific moments as needed and better support during critical transitions (e.g., when the donor body goes to the operating room). The theme of better connection to recipient(s) included receiving information about the donation surgery (e.g., which organs were recovered), establishing connection with recipients (e.g., via social networks or letters) and planned encounters. Support after donation, such as updates on organ transplantation, early mental health checks and continued connection to donor organizations, could be improved. We derived 20 suggestions for improving the organ donation process, derived from interviews with family members of pediatric and adult organ donors. INTERPRETATION: We found gaps in family support during end-of-life and donation care. Feelings of abandonment, lack of support and poor-to-little follow-up provide the empirical findings needed for hospitals and organ donor organizations to provide better support to donor families.

The impact of Oncotype DX breast cancer assay results on clinical practice: a UK experience.

BACKGROUND: Genomic tests are increasingly being used by clinicians when considering adjuvant chemotherapy for patients with oestrogen receptor-positive (ER+), human epidermal growth factor 2-negative (HER2-) breast cancer. The Oncotype DX breast recurrence score assay was the first test available in the UK National Health Service. This study looked at how UK clinicians were interpreting Recurrence Scores (RS) in everyday practice. METHODS: RS, patient and tumour characteristics and adjuvant therapy details were retrospectively collected for 713 patients from 14 UK cancer centres. Risk by RS-pathology-clinical (RSPC) was calculated and compared to the low/intermediate/risk categories, both as originally defined (RS < 18, 18-30 and > 30) and also using redefined boundaries (RS < 11, 11-25 and > 25). RESULTS: 49.8%, 36.2% and 14% of patients were at low (RS < 18), intermediate (RS 18-30) and high (RS > 30) risk of recurrence, respectively. Overall 26.7% received adjuvant chemotherapy. 49.2% of those were RS > 30; 93.3% of patients were RS > 25. Concordance between RS and RSPC improved when intermediate risk was defined as RS 11-25. CONCLUSIONS: This real-world data demonstrate the value of genomic tests in reducing the use of adjuvant chemotherapy in breast cancer. Incorporating clinical characteristics or RSPC scores gives additional prognostic information which may also aid clinicians' decision making.

Comparison of Whole-Body MRI, CT, and Bone Scintigraphy for Response Evaluation of Cancer Therapeutics in Metastatic Breast Cancer to Bone.

Background CT and bone scintigraphy have limitations in evaluating systemic anticancer therapy (SACT) response in bone metastases from metastatic breast cancer (MBC). Purpose To evaluate whether whole-body MRI enables identification of progressive disease (PD) earlier than CT and bone scintigraphy in bone-only MBC. Materials and Methods This prospective study evaluated participants with bone-only MBC between May 2016 and January 2019 (ClinicalTrials.gov identifier: NCT03266744). Participants were enrolled at initiation of first or subsequent SACT based on standard CT and bone scintigraphy imaging. Baseline whole-body MRI was performed within 2 weeks of entry; those with extraosseous disease were excluded. CT and whole-body MRI were performed every 12 weeks until definitive PD was evident with one or both modalities. In case of PD, bone scintigraphy was used to assess for bone disease progression. Radiologists independently interpreted images from CT, whole-body MRI, or bone scintigraphy and were blinded to results with the other modalities. Systematic differences in performance between modalities were analyzed by using the McNemar test. Results Forty-five participants (mean age, 60 years ± 13 [standard deviation]; all women) were evaluated. Median time on study was 36 weeks (range, 1-120 weeks). Two participants were excluded because of unequivocal evidence of liver metastases at baseline whole-body MRI, two participants were excluded because they had clinical progression before imaging showed PD, and one participant was lost to follow-up. Of the 33 participants with PD at imaging, 67% (22 participants) had PD evident at whole-body MRI only and 33% (11 participants) had PD at CT and whole-body MRI concurrently; none had PD at CT only (P < .001, McNemar test). There was only slight agreement between whole-body MRI and CT (Cohen κ, 0.15). PD at bone scintigraphy was reported in 50% of participants (13 of 26) with bone progression at CT and/or whole-body MRI (P < .001, McNemar test). Conclusion Whole-body MRI enabled identification of progressive disease before CT in most participants with bone-only metastatic breast cancer. Progressive disease at bone scintigraphy was evident in only half of participants with bone progression at whole-body MRI. © RSNA, 2020 Online supplemental material is available for this article.

A multicentre investigation of organ and tissue donation education for critical care residents.

PURPOSE: To describe critical care medicine residents' training, expertise, and skills regarding organ and tissue donation processes and procedures. METHODS: We undertook a qualitative multicentre study and employed a purposive sample of program directors, physicians, nurses, residents, and organ donation leaders from all nine academic intensive care unit (ICU) training centres (five adult, four pediatric) in Ontario (n = 71). Interviews, conducted by telephone between December 2015 and March 2016, were audio-recorded and transcribed verbatim. Data collection and analysis were performed using an iterative process and continued until saturation was achieved. RESULTS: Five main themes were identified: 1) gaps in residents' knowledge for both neurologic determination of death (NDD) and circulatory determination of death (DCD) cases; 2) commitment to the provision of organ and tissue donation training; 3) limited experiential learning (NDD and DCD); 4) challenges related to the provision of training on organ donation and need for a standardized curriculum; and 5) communication with family members. Overall, this study showed system-level gaps in training resulting from the lack of a standardized provincial curriculum on organ donation. CONCLUSIONS: Qualitative data corroborated that residents need more exposure to clinical cases, especially regarding DCD donors. A standardized education curriculum would be beneficial for all residents within the ICU. Developing a better shared understanding of the donation process will improve team communication and performance, translate into a better end-of-life experience for families, and potentially result in increased donation rates.

A Multicenter Qualitative Investigation of the Experiences and Perspectives of Substitute Decision Makers Who Underwent Organ Donation Decisions.

BACKGROUND: Organ donation research has centered on improving donation rates rather than focusing on the experience and impact on substitute decision makers. The purpose of this study was to document donor and nondonor family experiences, as well as lasting impacts of donation. METHODS: We used a qualitative exploratory design. Semistructured interviews of 27 next-of-kin decision makers were conducted, transcribed verbatim, and entered into qualitative software. We analyzed the process-based reflections using inductive coding and thematic analysis techniques. RESULTS: Four broad and interrelated themes emerged from the data: empathetic care, information needs, donation decision, and impact and follow-up. The donation experience left lasting impacts on family members due to lingering, unanswered questions. Suggested solutions to improve the donor experience for families included providers employing multimodal communication, ensuring a proper setting for family meetings, and the presence of a support person. DISCUSSION: We now have improved our understanding of the donation process from the perspective of and final impression from the next of kin. To our knowledge, this is the largest cohort interviewed in Canada. We have explored families' experiences, which included but did not end with donation. We learned that despite being appreciative of nurses, physicians, and organ and tissue donation coordinators, family members were often troubled by unanswered questions. CONCLUSION: This study described donor and nondonor family experiences with donation as well as lasting impacts. Addressing unanswered questions should be done in a place sufficiently remote from the donation event to enhance the family members' understanding and well-being.

Randomized pilot trial of yoga versus strengthening exercises in breast cancer survivors with cancer-related fatigue.

PURPOSE: Fatigue is one of the most common and bothersome refractory symptoms experienced by cancer survivors. Mindful exercise interventions such as yoga improve cancer-related fatigue; however, studies of yoga have included heterogeneous survivorship populations, and the effect of yoga on fatigued survivors remains unclear. METHODS: We randomly assigned 34 early-stage breast cancer survivors with cancer-related fatigue (≥4 on a Likert scale from 1-10) within 1 year from diagnosis to a 12-week intervention of home-based yoga versus strengthening exercises, both presented on a DVD. The primary endpoints were feasibility and changes in fatigue, as measured by the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). Secondary endpoint was quality of life, assessed by the Functional Assessment of Cancer Therapies-Breast (FACT-B). RESULTS: We invited 401 women to participate in the study; 78 responded, and we enrolled 34. Both groups had significant within-group improvement in multiple domains of the fatigue and quality of life scores from baseline to post-intervention, and these benefits were maintained at 3 months post-intervention. However, there was no significant difference between groups in fatigue or quality of life at any assessment time. Similarly, there was no difference between groups in adherence to the exercise intervention. CONCLUSIONS: Both DVD-based yoga and strengthening exercises designed for cancer survivors may be good options to address fatigue in breast cancer survivors. Both have reasonable uptake, are convenient and reproducible, and may be helpful in decreasing fatigue and improving quality of life in the first year post-diagnosis in breast cancer patients with cancer-related fatigue.

A qualitative study exploring mentorship in anesthesiology: perspectives from both sides of the relationship.

PURPOSE: Mentorship has been shown to improve career satisfaction, research productivity, and retention of academic physicians. There is a current lack of studies investigating factors that either promote or hinder effective mentoring relationships through the perspectives of both faculty and residents. The aim of this study was to ascertain these factors and subsequently to provide guidance on designing residency mentorship programs. METHODS: We used a qualitative design to examine mentorship experiences at the University of Ottawa Department of Anesthesiology and conducted semi-structured interviews with 11 residents and 12 faculty in the mentorship program. Data were analyzed iteratively using a constant comparative method to identify themes resulting in positive or negative mentorship outcomes. RESULTS: As determined from both mentor and mentee perspectives, a successful mentorship program hinges on three key factors-i.e., the anticipated goals of a mentorship relationship, characteristics of the participants, and the structure of the program. When themes were compared between mentors and mentees, differences in their perception of the goals of the relationship and the structure of the program resulted in cases of disillusionment and negative mentorship outcomes. The concept of a mentorship network emerged as a possible solution that would meet the evolving needs of mentees as they progress through training. The network would involve each mentee acquiring multiple mentors, with each providing guidance for a mentee's diverse areas of interest. CONCLUSION: We identified three key factors that facilitate or hinder mentorship relationships and proposed solutions for designing effective mentorship programs for postgraduate training programs.

The hidden and informal curriculum across the continuum of training: A cross-sectional qualitative study.

PURPOSE: The hidden and informal curricula refer to learning in response to unarticulated processes and constraints, falling outside the formal medical curriculum. The hidden curriculum has been identified as requiring attention across all levels of learning. We sought to assess the knowledge and perceptions of the hidden and informal curricula across the continuum of learning at a single institution. METHODS: Focus groups were held with undergraduate and postgraduate learners and faculty to explore knowledge and perceptions relating to the hidden and informal curricula. Thematic analysis was conducted both inductively by research team members and deductively using questions structured by the existing literature. RESULTS: Participants highlighted several themes related to the presence of the hidden and informal curricula in medical training and practice, including: the privileging of some specialties over others; the reinforcement of hierarchies within medicine; and a culture of tolerance towards unprofessional behaviors. Participants acknowledged the importance of role modeling in the development of professional identities and discussed the deterioration in idealism that occurs. CONCLUSIONS: Common issues pertaining to the hidden curriculum exist across all levels of learners, including faculty. Increased awareness of these issues could allow for the further development of methods to address learning within the hidden curriculum.

The hidden and informal curriculum across the continuum of training: A cross-sectional qualitative study.

PURPOSE: The hidden and informal curricula refer to learning in response to unarticulated processes and constraints, falling outside the formal medical curriculum. The hidden curriculum has been identified as requiring attention across all levels of learning. We sought to assess the knowledge and perceptions of the hidden and informal curricula across the continuum of learning at a single institution. METHODS: Focus groups were held with undergraduate and postgraduate learners and faculty to explore knowledge and perceptions relating to the hidden and informal curricula. Thematic analysis was conducted both inductively by research team members and deductively using questions structured by the existing literature. RESULTS: Participants highlighted several themes related to the presence of the hidden and informal curricula in medical training and practice, including: the privileging of some specialties over others; the reinforcement of hierarchies within medicine; and a culture of tolerance towards unprofessional behaviors. Participants acknowledged the importance of role modeling in the development of professional identities and discussed the deterioration in idealism that occurs. CONCLUSIONS: Common issues pertaining to the hidden curriculum exist across all levels of learners, including faculty. Increased awareness of these issues could allow for the further development of methods to address learning within the hidden curriculum.

Social media and medical education: Exploring the potential of Twitter as a learning tool.

This study set out to explore the ways in which social media can facilitate learning in medical education. In particular we were interested in determining whether the use of Twitter during an academic conference can promote learning for participants. The Twitter transcript from the annual International Conference on Residency Education (ICRE) 2013 was qualitatively analysed for evidence of the three overarching cognitive themes: (1) preconceptions, (2) frameworks, and (3) metacognition/refl ection in regard to the National Research Council ' s (NRC) How People Learn framework . Content analysis of the Twitter transcript revealed evidence of the three cognitive themes as related to how people learn. Twitter appears to be most effective at stimulating individuals ' preconceptions, thereby engaging them with the new material acquired during a medical education conference. The study of social media data, such as the Twitter data used in this study, is in its infancy. Having established that Twitter does hold signifi cant potential as a learning tool during an academic conference, we are now in a better position to more closely examine the spread, depth, and sustainability of such learning during medical education meetings.

Residents' reluctance to challenge negative hierarchy in the operating room: a qualitative study.

PURPOSE: Our aim was to clarify how hierarchy influences residents' reluctance to challenge authority with respect to clearly erroneous medical decision-making. METHODS: After research ethics approval, we recruited 44 anesthesia residents for a high-fidelity simulation scenario at two Ontario universities. During the scenario, an actor, whom the residents were told was an actual new staff anesthesiologist at their university, asked the trainees to give blood to a Jehovah's Witness in contradiction to the patient's explicitly stated wishes. Following the case, the trainees were debriefed and were interviewed for 30-40 min. The interviews were audio recorded and transcribed verbatim, and the text was coded using a qualitative approach informed by grounded theory. RESULTS: Qualitative analysis of the participants' interviews yielded rich descriptive accounts of hierarchical influences often characterized by fear and intimidation. Residents spoke about their coping strategies, which included adaptability, avoiding conflict, using inquiry as a method for patient advocacy, and relying on a diffusion of responsibility within the larger operating room team. CONCLUSIONS: Study results showed that hierarchy played a dominant role in the functioning of the operating room. Participants spoke of both the positive and negative effects of such a hierarchical learning environment. The majority of participants described a negative perception of hierarchy as the norm, and they employed many coping strategies. This study provides insight into how a negative hierarchical culture can adversely impact patient safety, resident learning, and team functioning. We propose a theoretical model to describe challenging authority in this context.

An Interhospital, Interdisciplinary Needs Assessment of Palliative Care in a Community Critical Care Context.

AIM: There is a paucity of data on the provision of palliative care in the critical care settings of smaller community hospitals. This study aimed to identify the gaps that affect the provision of palliative care in a community critical care setting. SETTING: The study was set in a 10-bed, open intensive care unit and emergency department at a community hospital. METHODS: Mixed methods were used. Quantitative data included those drawn from databases and surveys; qualitative data included those collected from interviews, focus groups, and onsite walk-throughs and were analyzed with inductive coding techniques. RESULTS: Gaps were identified in palliative care, goals of care and end-of-life discussions, and resources. Community hospital healthcare professionals did not fully appreciate their essential contribution to the provision of palliative care in the intensive care unit. In addition, there was a lack of expertise, and a lack of interest in gaining expertise, in palliative/end-of-life care. CONCLUSION: Interrelated needs in a complex interprofessional, interhospital context were captured. Further studies are required to obtain data on palliative practice in the care of critically ill patients in various community hospital contexts.

Comprehensive assessment of critical care needs in a community hospital*.

OBJECTIVE: To design and implement a needs assessment process that identifies gaps in caring for critically ill patients in a community hospital. DESIGN, SETTING, SUBJECTS: This mixed-method study was conducted between June 2011 and February 2012. A conceptual framework, centered on the critically ill patient, guided the design and selection of the data collection instruments. Different perspectives sampled included regional leaders, healthcare professionals at the community hospital and its referral hospital, as well as family members of patients who had received care at the community ICU. Data sources included interviews (n = 22), walk-throughs (n = 5), focus groups (n = 31), database searches, context questionnaires (n = 8), family surveys (n = 16), and simulations (n = 13). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nine needs were identified. At the community hospital, needs identified included lack of access to human resources, gaps in expertise, poor patient flow and ICU bed use, communication, lack of educational opportunities, and gaps in end-of-life care and interprofessional teamwork. Needs were also identified in the interhospital interaction between the community and referral hospitals, which included an inadequate hospital network and gaps in transfer and repatriation of patients. The methodology uncovered the causes and widespread impact of each need and how they interacted with one another. Proposed solutions by the participants are presented including both organizational and educational/clinical solutions. CONCLUSIONS: This study captured needs in a complex, interprofessional, interhospital context, which can be targeted with tailored interventions to improve patient outcomes in a community hospital. Furthermore, this study provides a preliminary framework and rigorous methodology to performing a needs assessment in this setting.