A Longitudinal Survey on Canadian Emergency Physician Burnout.

STUDY OBJECTIVE: Since Canada eased pandemic restrictions, emergency departments have experienced record levels of patient attendance, wait times, bed blocking, and crowding. The aim of this study was to report Canadian emergency physician burnout rates compared with the same physicians in 2020 and to describe how emergency medicine work has affected emergency physician well-being. METHODS: This longitudinal study on Canadian emergency physician wellness enrolled participants in April 2020. In September 2022, participants were invited to a follow-up survey consisting of the Maslach Burnout Inventory and an optional free-text explanation of their experience. The primary outcomes were emotional exhaustion and depersonalization levels, which were compared with the Maslach Burnout Inventory survey conducted at the end of 2020. A thematic analysis identified common stressors, challenges, emotions, and responses among participants. RESULTS: The response rate to the 2022 survey was 381 (62%) of 615 between September 28 and October 28, 2022, representing all provinces or territories in Canada (except Yukon). The median participant age was 42 years. In total, 49% were men, and 93% were staff physicians with a median of 12 years of work experience. 59% of respondents reported high emotional exhaustion, and 64% reported high depersonalization. Burnout levels in 2022 were significantly higher compared with 2020. Prevalent themes included a broken health care system, a lack of societal support, and systemic workplace challenges leading to physician distress and loss of physicians from the emergency workforce. CONCLUSION: We found very high burnout levels in emergency physician respondents that have increased since 2020.

From Slow Shifts to Fast Flips: Unraveling problem-based learning group function dynamics.

PURPOSE: Problem-Based Learning (PBL) relies on self-directed learning in small groups in the presence of a tutor. While the effectiveness of PBL is often attributed to the dynamics of group function, change in group function over time and factors influencing group function development are less understood. This study aims to explore the development of PBL group function over time to better understand the factors that give rise to high-functioning groups. METHOD: We examined time-function graphs of group function and conducted semi-structured focus group discussions in 2023 with medical students enrolled in a PBL curriculum. Students reflected on their experiences in four different PBL groups, creating time-function graphs to characterize development of group function over 8-12-week periods. We analyzed graphs and transcripts in a staged approach using qualitative description and direct content analysis, sensitized by two frameworks: Tuckman's Stages of Group Development and the Dimensions of PBL Group Function. RESULTS: Three archetypes of PBL group function development were identified: Slow Shifters, Fast Flippers, and Coasters. (1) Slow Shifters were characterized by a complex and extended pattern of growth consistent with Tuckman's model, typically occurring amongst inexperienced groups, or groups faced with a novel task. (2) Fast Flippers were characterized by abrupt state changes in group function arising from internal or external disruptions. (3) Coasters were characterized by plateaus, where maintenance of group function was a frequently cited challenge. Abrupt changes and plateaus occurred more among mature groups and groups with significant PBL experience. CONCLUSIONS: PBL group function varies over time in 3 different patterns. Classic Tuckman's stages are apparent among inexperienced groups, or groups facing novel tasks, whereas experienced groups often face abrupt change or plateaus. PBL educators and students should consider the need for novelty and disruption in more experienced groups to incite growth.

Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care.

STUDY OBJECTIVE: Given the popularity of educational blogs and podcasts in medicine, learners and educators need tools to identify trusted and impactful sites. The Social Media Index was a multi-sourced formula to rank the effect of emergency medicine and critical care blogs. In 2022, a key data point for the Social Media Index became unavailable. This bibliometric study aimed to develop a new measure, the Digital Impact Factor, as a replacement. METHODS: The Digital Impact Factor incorporated modern measures of website authority and reach. This formula was applied to a cross-sectional study of active emergency medicine and critical care blogs and podcasts. For each website, we generated a Digital Impact Factor score based on Ahrefs Domain Rating and the follower count of the websites' pages from 8 social media platforms. A series of Spearman correlations provided evidence of association by comparing a rank-ordered list to rank lists derived from the Social Media Index over the last 5 years. The Bland-Altman analysis assessed for agreement. RESULTS: The authors identified 88 relevant websites with a median Ahrefs Domain Rating of 28 (range 0 to 71, maximum 100) and total social media followership count across 8 platforms of 1,828,557. The Domain Rating and individual social media followership scores were normalized based on the highest recorded values to yield the Digital Impact Factor (median 4.57; range 0.02 to 9.50, maximum 10). The correlation between the 2022 Digital Impact Factor and the 2021 Social Media Index was 0.94 (95% confidence interval 0.89 to 0.97; p<.001; n=41 rankings correlated), suggesting that they measure similar constructs. The Bland-Altman plot also demonstrated fair agreement between the 2 scores. CONCLUSION: The Digital Impact Factor is a measure of the relative effect of educational blogs and podcasts within emergency medicine and critical care.

Characteristics of Emergency Medicine Residency Programs With Unfilled Positions in the 2023 Match.

STUDY OBJECTIVE: The unprecedented number of unfilled emergency medicine post-graduate year 1 (PGY-1) residency positions in the 2023 National Resident Matching Program shocked the emergency medicine community. This study investigates the association between emergency medicine program characteristics and the likelihood of unfilled positions in the 2023 Match. METHODS: This cross-sectional, observational study examined 2023 National Resident Matching Program data, focusing on program type, length, location, size, proximity to other programs, previous American Osteopathic Association (AOA) accreditation, first accreditation year, and emergency department ownership structure. We constructed a generalized linear mixed model with a logistic linking function to determine predictors of unfilled positions. RESULTS: A total of 554 of 3,010 (18.4%) PGY-1 positions at 131 of 276 (47%) emergency medicine programs went unfilled in the 2023 Match. In our model, predictors included having unfilled positions in the 2022 Match (odds ratio [OR] 48.14, 95% confidence interval [CI] 21.04 to 110.15), smaller program size (less than 8 residents, OR 18.39, 95% CI 3.90 to 86.66; 8 to 10 residents, OR 6.29, 95% CI 1.50 to 26.28; 11 to 13 residents, OR 5.88, 95% CI 1.55 to 22.32), located in the Mid Atlantic (OR 14.03, 95% CI 2.56 to 77.04) area, prior AOA accreditation (OR 10.13, 95% CI 2.82 to 36.36), located in the East North Central (OR 6.94, 95% CI 1.25 to 38.47) area, and corporate ownership structure (OR 3.21, 95% CI 1.06 to 9.72). CONCLUSION: Our study identified 6 characteristics associated with unfilled emergency medicine residency positions in the 2023 Match. These findings may be used to guide student advising and inform decisions by residency programs, hospitals, and national organizations to address the complexities of residency recruitment and implications for the emergency medicine workforce.

His opportunity, her burden: A narrative critical review of why women decline academic opportunities.

OBJECTIVES: This paper stems from a desire to deepen our own understanding of why women might 'say no' when allies and sponsors offer or create opportunities for advancement, leadership or recognition. The resulting disparity between representation by men and women in leadership positions, invited keynote speakers and publication counts in academic medicine is a stubborn and wicked problem that requires a synthesis of knowledge across multidisciplinary literature. Acknowledging the complexity of this topic, we selected a narrative critical review methodology to explore reasons why one man's opportunity might be a woman's burden in academic medicine. METHODS: We engaged with an iterative process of identifying, reviewing and interpreting literature from Psychology (cognitive, industrial and educational), Sociology, Health Professions Education and Business, placing no restrictions on context or year of publication. Knowledge synthesis and interpretation were guided by our combined expertise, lived experience, consultations with experts outside the author team and these guiding questions: (1) Why might women have less time for career advancement opportunities? (2) Why do women have less time for research and leadership? (3) How are these disparities maintained? RESULTS: Turning down an opportunity may be a symptom of a much larger issue. The power of social expectations, culture and gender stereotypes remains a resistant force against calls for action. Consequently, women disproportionately take on other tasks that are not as well recognised. This disparity is maintained through social consequences for breaking with firmly entrenched stereotypes. CONCLUSIONS: Popular strategies like 'lean into opportunities', 'fake it till you make it' and 'overcome your imposter syndrome' suggest that women are standing in their own way. Critically, these axioms ignore powerful systemic barriers that shape these choices and opportunities. We offer strategies that allies, sponsors and peers can implement to offset the power of stereotypes.

LEADS+ Developmental Model: Proposing a new model based on an integrative conceptual review.

BACKGROUND: Leaders in academic health sciences centres (AHCs) must navigate multiple roles as an inherent component of their positions. Changing accountabilities, varying expectations, differing leadership capabilities required of multiple leadership roles can be exacerbated by health system disruption, such as during the COVID-19 pandemic. We need improved models that support leaders in navigating the complexity of multiple leadership roles. METHOD: This integrative conceptual review sought to examine leadership and followership constructs and how they intersect with current leadership practices in AHCs. The goal was to develop a refined model of healthcare leadership development. The authors used iterative cycles of divergent and convergent thinking to explore and synthesise various literature and existing leadership frameworks. The authors used simulated personas and stories to test the model and, finally, the approach sought feedback from knowledge users (including healthcare leaders, medical educators and leadership developers) to offer refinements. RESULTS: After five rounds of discussion and reformulation, the authors arrived at a refined model: the LEADS+ Developmental Model. The model describes four nested stages, organising progressive capabilities, as an individual toggles between followership and leadership. During the consultation stage, feedback from 29 out of 65 recruited knowledge users (44.6% response rate) was acquired. More than a quarter of respondents served as a senior leader in a healthcare network or national society (27.5%, n = 8). Consulted knowledge users were invited to indicate their endorsement for the refined model using a 10-point scale (10 = highest level of endorsement). There was a high level of endorsement: 7.93 (SD 1.7) out of 10. CONCLUSION: The LEADS+ Developmental Model may help foster development of academic health centre leaders. In addition to clarifying the synergistic dynamic between leadership and followership, this model describes the paradigms adopted by leaders within health systems throughout their development journey.

Defining new roles and competencies for administrative staff and faculty in the age of competency-based medical education.

PURPOSE: These authors sought to define the new roles and competencies required of administrative staff and faculty in the age of CBME. METHOD: A modified Delphi process was used to define the new CBME roles and competencies needed by faculty and administrative staff. We invited international experts in CBME (volunteers from the ICBME Collaborative email list), as well as faculty members and trainees identified via social media to help us determine the new competencies required of faculty and administrative staff in the CBME era. RESULTS: Thirteen new roles were identified. The faculty-specific roles were: National Leader/Facilitator in CBME; Institutional/University lead for CBME; Assessment Process & Systems Designer; Local CBME Leads; CBME-specific Faculty Developers or Trainers; Competence Committee Chair; Competence Committee Faculty Member; Faculty Academic Coach/Advisor or Support Person; Frontline Assessor; Frontline Coach. The staff-specific roles were: Information Technology Lead; CBME Analytics/Data Support; Competence Committee Administrative Assistant. CONCLUSIONS: The authors present a new set of faculty and staff roles that are relevant to the CBME context. While some of these new roles may be incorporated into existing roles, it may be prudent to examine how best to ensure that all of them are supported within all CBME contexts in some manner.

Humans not heroes: Canadian emergency physician experiences during the early COVID-19 pandemic.

BACKGROUND: The pandemic has upended much clinical care, irrevocably changing our health systems and thrusting emergency physicians into a time of great uncertainty and change. This study is a follow-up to a survey that examined the early pandemic experience among Canadian emergency physicians and aimed to qualitatively describe the experiences of these physicians during the global pandemic. The study was conducted at a time when Canadian COVID-19 case numbers were low. METHODS: The investigators engaged in an interview-based study that used an interpretive description analytic technique, sensitised by the principles of phenomenology. One-to-one interviews were conducted, transcribed and then analysed to establish a codebook, which was subsequently grouped into key themes. Results underwent source triangulation (with survey data from a similar period) and investigator-driven audit trail analysis. RESULTS: A total of 16 interviews (11 female, 5 male) were conducted between May and September 2020. The isolated themes on emergency physicians' experiences during the early pandemic included: (1) disruption and loss of emergency department shift work; (2) stress of COVID-19 uncertainty and information bombardment; (3) increased team bonding; (4) greater personal life stress; (5) concern for patients' isolation, miscommunication and disconnection from care; (6) emotional distress. CONCLUSIONS: Canadian emergency physicians experienced emotional and psychological distress during the early COVID-19 pandemic, at a time when COVID-19 prevalence was low. This study's findings could guide future interventions to protect emergency physicians against pandemic-related distress.

Off-Script, Online: Virtual Medical Improv Pilot Program for Enhancing Well-being and Clinical Skills among Psychiatry Residents.

OBJECTIVE: Clinical interactions demand a balance of structure and flexibility in response to unpredictable situations. Medical improv is a form of experiential learning that applies techniques from improvisational theater to the healthcare setting, deliberately targeting clinical skills of communication, teamwork, and cognitive abilities. Psychiatry Education through Play and Talk (PEP Talks) is a novel medical improv program designed specifically for psychiatry residents with the goal of improving communication, teamwork, and conflict resolution skills, as well as enhancing residents' well-being and capacity for self-reflection. METHODS: PEP Talks was delivered virtually by an experienced medical improv facilitator in spring 2021 to a self-selected group of psychiatry residents at a Canadian university. Aligned with the context-input-process-product (CIPP) evaluation model, outcomes were assessed through mixed methods surveys, recorded debriefings, and a focus group. RESULTS: PEP Talks enhanced residents' self-reported well-being, reflective capacity, and communication skills. Participants made qualitative connections between PEP Talks and their well-being, inter- and intra-personal skills, and clinical experiences in psychiatry. Processes in PEP Talks that led to these outcomes included the following: joy, building community, personal reflection and discovery, going off-script, immersion, and virtual engagement. CONCLUSIONS: Virtual medical improv offers an innovative solution to the pedagogical challenges of training psychiatrists to be proficient communicators, collaborators, and professionals capable of reflective practice. Additionally, this innovation demonstrates that medical improv can be delivered in a virtual format and may offer a unique solution to support resident well-being and foster connection amid remote learning during a global pandemic.

Identifying Social Media Competencies for Health Professionals: An International Modified Delphi Study to Determine Consensus for Curricular Design.

STUDY OBJECTIVE: The use of social media by health professionals is widespread. However, there is a lack of training to support the effective use of these novel platforms that account for the nuances of an effective health and research communication. We sought to identify the competencies needed by health care professionals to develop an effective social media presence as a medical professional, with the goal of building a social media curriculum. METHODS: We conducted a modified Delphi study, utilizing Kraiger's Knowledge, Skills, and Attitudes framework to identify appropriate items for inclusion in a social media curriculum targeted at health care professionals. Experts in this space were defined as health care professionals who had delivered workshops, published papers, or developed prominent social media tools/accounts. They were recruited through a multimodal campaign to complete a series of 3 survey rounds designed to build consensus. In keeping with prior studies, a threshold of 80% endorsement was used for inclusion in the final list of items. RESULTS: Ninety-eight participants met the expert criteria and were invited to participate in the study. Of the 98 participants, 92 (94%) experts completed the first round; of the 92 experts who completed the first round, 83 (90%) completed the second round; and of the 83 experts who completed the second round, 81 (98%) completed the third round of the Delphi study. Eighteen new items were suggested in the first survey and incorporated into the study. A total of 46 items met the 80% inclusion threshold. CONCLUSION: We identified 46 items that were believed to be important for health care professionals using social media. This list should inform the development of curricular activities and objectives.

Confidence-competence alignment and the role of self-confidence in medical education: A conceptual review.

CONTEXT: There have been significant advances in competency-based medical education (CBME) within health professions education. While most of the efforts have focused on competency, less attention has been paid to the role of confidence as a factor in preparing for practice. This paper seeks to address this deficit by exploring the role of confidence and the calibration of confidence with regard to competence. METHODS: This paper presents a conceptual review of confidence and the calibration of confidence in different medical education contexts. Building from an initial literature review, the authors engaged in iterative discussions exploring divergent and convergent perspectives, which were then supplemented with targeted literature reviews. Finally, a stakeholder consultation was conducted to situate and validate the provisional findings. RESULTS: A series of axioms were developed to guide perceptions and responses to different states of confidence in health professionals: (a) confidence can shape how we act and is optimised when it closely corresponds to reality; (b) self-confidence is task-specific, but also inextricably influenced by the individual self-conceptualisation, the surrounding system and society; (c) confidence is shaped by many external factors and the context of the situation; (d) confidence must be considered in conjunction with competence and (e) the confidence-competence ratio (CCR) changes over time. It is important to track learners' CCRs and work with them to maintain balance. CONCLUSION: Confidence is expressed in different ways and is shaped by a variety of modifiers. While CBME primarily focuses on competency, proportional confidence is an integral component in ensuring safe and professional practice. As such, it is important to consider both confidence and competence, as well as their relationship in CBME. The CCR can serve as a key construct in developing mindful and capable health professionals. Future research should evaluate strategies for assessing CCR, identify best practices for teaching confidence and guiding self-calibration of CCR and explore the role of CCR in continuing professional development for individuals and teams.

COVID-19 and the transition to virtual teaching sessions in an orthopaedic surgery training program: a survey of resident perspectives.

BACKGROUND: COVID-19 has had a tremendous impact on medical education. Due to concerns of the virus spreading through gatherings of health professionals, in-person conferences and rounds were largely cancelled. The purpose of this study is the evaluate the implementation of an online educational curriculum by a major Canadian orthopaedic surgery residency program in response to COVID-19. METHODS: A survey was distributed to residents of a major Canadian orthopaedic surgery residency program from July 10th to October 24th, 2020. The survey aimed to assess residents' response to this change and to examine the effect that the transition has had on their participation, engagement, and overall educational experience. RESULTS: Altogether, 25 of 28 (89%) residents responded. Respondents generally felt the quality of education was superior (72%), their level of engagement improved (64%), and they were able to acquire more knowledge (68%) with the virtual format. Furthermore, 88% felt there was a greater diversity of topics, and 96% felt there was an increased variety of presenters. Overall, 76% of respondents felt that virtual seminars better met their personal learning objectives. Advantages reported were increased accessibility, greater convenience, and a wider breadth of teaching faculty. Disadvantages included that the virtual sessions felt less personal and lacked dynamic feedback to the presenter. CONCLUSIONS: Results of this survey reveal generally positive attitudes of orthopaedic surgery residents about the transition to virtual learning in the setting of an ongoing pandemic. This early evaluation and feedback provides valuable guidance on how to grow this novel curriculum and bring the frontier of virtual teaching to orthopaedic education long-term.

Physician choices in pulmonary embolism testing.

BACKGROUND: Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians' test choices for PE. METHODS: We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests. RESULTS: We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE. INTERPRETATION: Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.

Sex Distribution of Editorial Board Members Among Emergency Medicine Journals.

STUDY OBJECTIVE: Previous studies have demonstrated that a sex disparity exists in the editorial boards of select specialties. However, there are limited data with respect to emergency medicine. We seek to determine the sex distribution of editors in chief and editorial board members among emergency medicine journals. METHODS: In this cross-sectional survey, we compiled a list of all emergency medicine journals, using the Scimago Journal & Country Rank on August 13, 2019. We excluded journals that were no longer published, were not emergency medicine journals, had rotating editorial boards for each issue, or had no first names listed. We obtained the sex and editorial board role by using publicly available data on the journal Web sites. We assigned sex according to knowledge of the member or his or her online faculty profile and used the Genderize program (Genderize.io, Roskilde, Denmark) when sex could not be determined with the above-mentioned approach. We report descriptive statistics for the categoric data, stratified by position (editor in chief, editorial board member, social media editor, resident/fellow member) and country. RESULTS: We identified 73 journals in Scimago; 37 met inclusion criteria, with data available to determine the sex in 99.5% of cases. There were 46 total editors in chief, with only 4 (8.7%) being women. Of 1,477 total editorial board members, only 241 were women (16.3%), with a range of 0% to 33.3% per journal. We found that 28.6% of social media editors (2/7) at 4 journals and 70% of resident or fellow editors (7/10) at 5 journals were women. CONCLUSION: There is a notable sex disparity among emergency medicine journals' editors in chief and editorial board members. Efforts should be made to improve sex distribution among editorial boards.

Neurology podcast utilization during the COVID-19 pandemic.

BACKGROUND: As medical education shifted to a virtual environment during the early coronavirus disease 2019 (COVID-19) pandemic, we evaluated how neurology podcasting may have been utilized during this period, and which features of podcasts have been more highly sought by a medical audience. METHODS: We conducted a retrospective analysis of neurology-themed blogs and/or podcasts between April 2019 and May 2020. Programs were eligible if they reported mean monthly downloads > 2000, were affiliated with an academic society, or offered continuing medical education credit. Thirty-day download counts were compared between study months, with adjustment for multiple testing. Exploratory analyses were performed to determine which podcast features were associated with higher downloads. RESULTS: Of the 12 neurology podcasts surveyed, 8 completed the survey and 5 met inclusion criteria. The median monthly download count was 2865 (IQR 869-7497), with significant variability between programs (p < 0.001). While there was a 358% increase in downloads during April 2020 when compared to the previous month, this was not significant (median 8124 [IQR 2913-14,177] vs. 2268 [IQR 540-6116], padj = 0.80). The non-significant increase in overall downloads during April 2020 corresponded to an increase in unique episodes during that month (r = 0.48, p = 0.003). There was no difference in 30-day downloads among episodes including COVID-19 content versus not (median 1979 [IQR 791-2873] vs. 1171 [IQR 405-2665], p = 0.28). CONCLUSIONS: In this unique, exploratory study of academic neurology-themed podcasts, there was no significant increase in episode downloads during the early COVID-19 pandemic. A more comprehensive analysis of general and subspecialty medical podcasts is underway.

Assessment of the potential allergenicity and toxicity of Pichia proteins in a novel leghemoglobin preparation.

The production of soy leghemoglobin C2 (LegH) by Pichia pastoris (syn. K. phaffii) was developed by Impossible Foods to serve as a sustainable source of flavor and aroma in plant-based meats. The potential allergenicity and toxicity of a LegH from a new production process was analyzed using bioinformatics, proteomics and a pepsin digestion assay on leghemoglobin, and residual host proteins. LegH in the new preparation had the same proteoform as in the previous preparations as well as in soy root nodule extracts. Results of seven Pichia proteins, each representing ≥1% of the total protein content, showed no significant sequence matches to any known allergens with the exception of one, which matched the highly conserved wheat GAPDH, whose protein homolog is found in fungi and humans. Based on the data, it is unlikely that there is any risk of cross reactivity between LegH Prep and GAPDH. Pichia protein sequences showed very good alignment to homologous proteins from many common yeasts including Saccharomyces sp. In addition, LegH and Pichia proteins were all rapidly digested in a pepsin digest assay. In conclusion, LegH Prep from this P. pastoris production process is unlikely to pose a risk of food allergenicity.

If we could turn back time: Imagining time-variable, competency-based medical education in the context of COVID-19.

The COVID-19 pandemic has exposed a paradox in historical models of medical education: organizations responsible for applying consistent standards for progression have needed to adapt to training environments marked by inconsistency and change. Although some institutions have maintained their traditional requirements, others have accelerated their programs to rush nearly graduated trainees to the front lines. One interpretation of the unplanned shortening of the duration of training programs during a crisis is that standards have been lowered. But it is also possible that these trainees were examined according to the same standards as usual and were judged to have already met them. This paper discusses the impacts of the COVID-19 pandemic on the current workforce, provides an analysis of how competency-based medical education (CBME) in the context of the pandemic might have mitigated wide-scale disruption, and identifies structural barriers to achieving an ideal state. The paper further calls upon universities, health centres, governments, certifying bodies, regulatory authorities, and health care professionals to work collectively on a truly time-variable model of CBME. The pandemic has made clear that time variability in medical education already exists and should be adopted widely and formally. If our systems today had used a framework of outcome competencies, sequenced progression, tailored learning, focused instruction, and programmatic assessment, we may have been even more nimble in changing our systems to care for our patients with COVID-19.

Becoming a deliberately developmental organization: Using competency based assessment data for organizational development.

Medical education is situated within health care and educational organizations that frequently lag in their use of data to learn, develop, and improve performance. How might we leverage competency-based medical education (CBME) assessment data at the individual, program, and system levels, with the goal of redefining CBME from an initiative that supports the development of physicians to one that also fosters the development of the faculty, administrators, and programs within our organizations? In this paper we review the Deliberately Developmental Organization (DDO) framework proposed by Robert Kegan and Lisa Lahey, a theoretical framework that explains how organizations can foster the development of their people. We then describe the DDO's conceptual alignment with CBME and outline how CBME assessment data could be used to spur the transformation of health care and educational organizations into digitally integrated DDOs. A DDO-oriented use of CBME assessment data will require intentional investment into both the digitalization of assessment data and the development of the people within our organizations. By reframing CBME in this light, we hope that educational and health care leaders will see their investments in CBME as an opportunity to spur the evolution of a developmental culture.

Diagnosing conflict: Conflicting data, interpersonal conflict, and conflicts of interest in clinical competency committees.

Clinical competency committees (CCCs) are increasingly used within health professions education as their decisions are thought to be more defensible and fairer than those generated by previous training promotion processes. However, as with most group-based processes, it is inevitable that conflict will arise. In this paper the authors explore three ways conflict may arise within a CCC: (1) conflicting data submissions that are presented to the committee, (2) conflicts between members of the committee, and (3) conflicts of interest between a specific committee member and a trainee. The authors describe each of these conflict situations, dissect out the underlying problems, and explore possible solutions based on the current literature.

Peek at the glass ceiling: gender distribution of leadership among emergency medicine residency programs.

BACKGROUND: A gender gap in faculty rank at academic institutions exists; however, data among graduate medical education (GME) programmes are limited. There is a need to assess gender disparities in GME leadership, as a lack of female leadership may affect recruitment, role modelling and mentorship of female trainees. This cross-sectional study aimed to describe the current state of gender in programme leadership (department chair, programme director (PD), associate/assistant PD (APD) and clerkship director (CD)) at accredited Emergency Medicine (EM) programmes in the USA to determine whether a gender gap exists. METHODS: A survey was distributed to EM residency programmes in the USA assessing demographics and gender distribution among programme leadership. If no response was received, information was collected via the programme's website. Data were organised by position, region and length of the programme. We obtained data on the number of female EM physicians in practice and in training/fellowship in 2017 from the Association of American Medical Colleges. Data analysis was completed using descriptive statistics and χ2 analysis. RESULTS: Of the 226 programmes contacted, 148 responded to the survey (66.3%). Among US EM residency programmes, 11.2% of chairs, 34.6% of PDs, 40.5% of APDs and 46.5% of CDs are women. The percentage of female chairs is significantly lower than the percentage of women in practice or in training in EM. The percentage of female PDs did not differ from the percentage of women in practice or in training in EM. The percentage of female APDs and CDs was significantly higher than the percentage of women in practice but did not differ from the percentage in training. There was wide variability across regions. Four-year programmes had more women in PD and APD positions compared with 3-year programmes (p=0.01). CONCLUSIONS: While the representation of women in educational roles is encouraging, the number of women holding the rank of chairperson remains disproportionately low. Further studies are needed to evaluate reasons for this and strategies to increase gender equality in leadership roles.