Ottawa 2020 consensus statement for programmatic assessment - 1. Agreement on the principles.

INTRODUCTION: In the Ottawa 2018 Consensus framework for good assessment, a set of criteria was presented for systems of assessment. Currently, programmatic assessment is being established in an increasing number of programmes. In this Ottawa 2020 consensus statement for programmatic assessment insights from practice and research are used to define the principles of programmatic assessment. METHODS: For fifteen programmes in health professions education affiliated with members of an expert group (n = 20), an inventory was completed for the perceived components, rationale, and importance of a programmatic assessment design. Input from attendees of a programmatic assessment workshop and symposium at the 2020 Ottawa conference was included. The outcome is discussed in concurrence with current theory and research. RESULTS AND DISCUSSION: Twelve principles are presented that are considered as important and recognisable facets of programmatic assessment. Overall these principles were used in the curriculum and assessment design, albeit with a range of approaches and rigor, suggesting that programmatic assessment is an achievable education and assessment model, embedded both in practice and research. Knowledge on and sharing how programmatic assessment is being operationalized may help support educators charting their own implementation journey of programmatic assessment in their respective programmes.

Ottawa 2020 consensus statements for programmatic assessment - 2. Implementation and practice.

INTRODUCTION: Programmatic assessment is a longitudinal, developmental approach that fosters and harnesses the learning function of assessment. Yet the implementation, a critical step to translate theory into practice, can be challenging. As part of the Ottawa 2020 consensus statement on programmatic assessment, we sought to provide descriptions of the implementation of the 12 principles of programmatic assessment and to gain insight into enablers and barriers across different institutions and contexts. METHODS: After the 2020 Ottawa conference, we surveyed 15 Health Profession Education programmes from six different countries about the implementation of the 12 principles of programmatic assessment. Survey responses were analysed using a deductive thematic analysis. RESULTS AND DISCUSSION: A wide range of implementations were reported although the principles remained, for the most part, faithful to the original enunciation and rationale. Enablers included strong leadership support, ongoing faculty development, providing students with clear expectations about assessment, simultaneous curriculum renewal and organisational commitment to change. Most barriers were related to the need for a paradigm shift in the culture of assessment. Descriptions of implementations in relation to the theoretical principles, across multiple educational contexts, coupled with explanations of enablers and barriers, provided new insights and a clearer understanding of the strategic and operational considerations in the implementation of programmatic assessment. Future research is needed to further explore how contextual and cultural factors affect implementation.

The alignment imperative in curriculum renewal.

RATIONALE: There are perennial calls for MD curricula to reform in order to meet the changing needs of students, patients, and society. And yet, efforts at renewal have also been suggested to have minimal impact on the pedagogy and outcomes of medical education. One reason may be misalignment between the components of the curriculum during design and implementation. The University of Toronto MD program recently renewed its undergraduate preclinical Foundations curriculum. Mindful of the pitfalls of misalignment, the renewal process focused deliberately on alignment between the various components of the curriculum: instructional methods, student assessment, faculty development, and the larger purpose of serving students and society. INNOVATION: Educational evidence was used to drive the alignment process which resulted in three major changes. First, we created a spiral curriculum centered on 72 virtual patient cases designed to integrate content and prepare students for clinical learning. Second, we introduced a novel medical psychiatry component to address a core societal need in mental health. This exposed students early to experiences of complexity, ambiguity, and integrated patient care. Lastly, a shift to assessment for learning and programmatic assessment was designed and implemented concurrently to reinforce the pedagogy of the curriculum. Synchronous faculty development was developed for the new roles required of faculty. CONCLUSIONS: Early program evaluation shows alignment of these curricular components requires ongoing attention and resources in order to be successful. The potential benefits of this alignment are well prepared students who can meet the needs of their patients and society in an increasingly complex health system.

'Who is on your health-care team?' Asking individuals with heart failure about care team membership and roles.

BACKGROUND: Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient-centred care. OBJECTIVES: To explore how individuals with HF conceptualize their care team, and perceive team members' roles. SETTING AND PARTICIPANTS: Individuals with advanced HF were recruited from five cities in three Canadian provinces. DESIGN: Individuals were asked to identify their HF care team during semi-structured interviews. Team members' titles and roles, quotes pertaining to team composition and function, and frailty criteria were extracted and analysed using descriptive statistics and content analysis. RESULTS: A total of 62 individuals with HF identified 2-19 team members. Caregivers, nurses, family physicians and cardiologists were frequently identified; teams also included dentists, foot care specialists, drivers, housekeepers and spiritual advisors. Most individuals met frailty criteria and described participating in self-management. DISCUSSION: Individuals with HF perceived being active participants, not passive recipients, of care. They identified teams that were larger and more diverse than traditional biomedical conceptualizations. However, the nature and importance of team members' roles varied according to needs, relationships and context. Patients' degree of agency was negotiated within this context, causing multiple, sometimes conflicting, responses. CONCLUSION: Ignoring the patient's role on the care team may contribute to fragmented care. However, understanding the team through the patient's lens - and collaborating meaningfully among identified team members - may improve health-care delivery.

Adaptive practices in heart failure care teams: implications for patient-centered care in the context of complexity.

BACKGROUND: Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care's holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease. METHODS: Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory. RESULTS: This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: "the way things work around here", which were commonplace, routine ways of doing things, and "the way we make things work around here", which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings. CONCLUSION: Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care's growing challenge of providing care to those with chronic medical illness in complex, team-based settings.

Residents learning from a narrative experience with dying patients: a qualitative study.

For patients at the end of life, it is crucial to address the psychological, existential, and spiritual distress of patients. Medical education research suggests trainees feel unprepared to provide the whole person, humanistic care held as the ideal. This study used an empirically based narrative intervention, the dignity interview, as an educational intervention with first year residents. The interview helps patients tell and make meaning of their life story. The intervention was aimed at addressing trainee perceived gaps in the non-physical aspects of end-of-life care. It was also intended to stimulate broader reflection on lessons learned in medical education about the value of narrative as part of humanistic care. Twelve first year residents administered a 1 h interview to dying patients. The resident returned to read the transcribed story back to the patient. Semi-structured interviews of the residents were transcribed and analyzed using the constant comparative method to identify emergent themes. This experience was seen as distinct from the 'traditional" medical interview. Residents reflected on lessons learned from patients and on their own professional and personal lives. Residents felt conversations with dying patients, and more broadly the art of soliciting a patient's story are poorly taught and modeled. More concerning, the hidden curriculum seems to be sending messages that learning a patient's story is not the domain of a physician and that it is not valued like the curing and technical imperatives. These findings have implications for medical education's ongoing attempts to better produce humanistic physicians.

Understanding palliative care on the heart failure care team: an innovative research methodology.

CONTEXT: There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team. OBJECTIVES: To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team. METHODS: This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams. RESULTS: We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps. CONCLUSION: We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

Exploring the therapeutic power of narrative at the end of life: a qualitative analysis of narratives emerging in dignity therapy.

OBJECTIVE: To understand the therapeutic effect of a narrative intervention, specifically dignity therapy, in patients at the end-of-life. To examine the thematic dimensions and shared narrative features of the stories that emerge in dignity therapy and theorise their relationship to the intervention's clinical impact. DESIGN: Resident physicians, as part of an educational intervention, co-administered the dignity therapy protocol with the principal investigator. Interviews were transcribed, edited, and then, within a week, read back to the patient and provided as a document for the patient to keep. A constant comparative approach was taken to identify narratives and thematic patterns. PARTICIPANTS: 12 Patients at the end-of-life were administered dignity interviews by 12 resident physicians, accompanied by the principal investigator. SETTING: Palliative care settings in two University of Toronto academic hospitals. RESULTS: Three narrative types emerged, each containing several themes. Evaluation narratives create a life lived before illness, with an overarching theme of overcoming adversity. Transition narratives describe a changing health situation and its meanings, including impact on family and on one's world view. Legacy narratives discuss the future without the patient and contain the parables and messages to be left for loved ones. CONCLUSIONS: While the interview protocol guides patients' responses, the commonality of narrative structures across interviews suggests that patients draw on experiences with two familiar genres: the eulogy and the medical interview, to create a narrative order during the chaos of dying. The dignity interview's resonance with these genres appears to facilitate a powerful, and perhaps unexpected sense of agency.

End-of-life care education for psychiatric residents: attitudes, preparedness, and conceptualizations of dignity.

OBJECTIVE: The authors examined psychiatric residents' attitudes, perceived preparedness, experiences, and needs in end-of-life care education. They also examined how residents conceptualized good end-of-life care and dignity. METHODS: The authors conducted an electronic survey of 116 psychiatric residents at the University of Toronto. The survey had a mix of qualitative and quantitative questions. RESULTS: Eighty-two of 116 invited psychiatric residents participated for a response rate of 71%. With favorable attitudes, residents felt least prepared in existential, spiritual, cultural, and some psychological aspects of caring for dying patients. Trainees conceptualized dignity at the end of life in a way very similar to that of patients, including concerns of the mind, body, soul, relationships, and autonomy. Residents desired more longitudinal, contextualized training, particularly in the psychosocial, existential, and spiritual aspects of care. CONCLUSION: This is the first study to examine the end-of-life educational experience of psychiatric residents. Despite conceptualizing quality care and the construct of dignity similarly to dying patients, psychiatric residents feel poorly prepared to deliver such care, particularly the nonphysical aspects of caring for the dying. These results will inform curriculum development in end-of-life care for psychiatric residents, a complex area now considered a core competency.

The research innovation and scholarship in education program: an innovative way to nurture education.

OBJECTIVE: Education is becoming a recognized career path in psychiatry. Yet, there are few published accounts of how to create sustainable structures within departments to support this academic focus. The authors document the creation and 5-year progress of the Research Innovation and Scholarship in Education (RISE) program at the largest psychiatry department in Canada. METHODS: The authors analyzed the RISE archive of early proposals for enhancing scholarship in the department, the 5-year plan, annual reports, and curricular vitae of members and also gathered testimonials from inaugural residents and fellows of the program. Materials were analyzed using Boyer's framework of scholarship. RESULTS: Organizationally, RISE has embodied all four tenets of Boyer's model of scholarship. The program has allowed education research, teaching, and creative professional development to flourish in the department, and there are considerably fewer barriers to pursuing an education career path. However, as the program expands, more work needs to be done to increase funding and protected time so that even more residents, fellows, and faculty can engage in educational scholarship. CONCLUSION: Enhancing medical education scholarship through a model that actively integrates research with teaching, creative professional development, and mentorship can help the trajectories of faculty and students wishing to make education a priority in their careers.