Improving Breath Detection From Pulsed-Flow Oxygen Sources Using a New Nasal Interface.

BACKGROUND: Patients with COPD and other lung diseases are treated with long-term oxygen therapy (LTOT). Portable oxygen sources are required to administer LTOT while maintaining patient autonomy. Existing portable oxygen equipment has limitations that can hinder patient mobility. A novel nasal interface is presented in this study, aiming to enhance breath detection and triggering efficiency of portable pulsed-flow oxygen devices, thereby improving patient mobility and independence. METHOD: To examine the effectiveness of the new interface, 8 respiratory therapists participated in trials using different oxygen sources (tank with oxygen-conserving device, SimplyGo Mini portable oxygen concentrator [POC], and OxyGo NEXT POC) and breathing types (nasal and oral) while using either the new nasal interface or a standard cannula. Each trial was video recorded so participant breaths could be retroactively matched with a pulse/no-pulse response, and triggering success rates were calculated by dividing the number of oxygen pulses by the number of breaths in each trial. After each trial, volunteers were asked to rate their perceived breathing resistance. RESULTS: Nasal breathing consistently resulted in higher triggering success rates compared to oral breathing for pulsed-flow oxygen devices. POCs exhibited higher triggering success rates than did the oxygen tanks with conserving device. However, there were no significant differences in triggering success rates between the two POC models. The new nasal interface demonstrated improved triggering success rates compared to the standard cannula. Whereas the new nasal interface was associated with a slight increase in perceived breathing resistance during nasal breathing trials, participants reported manageable resistance levels when using the interface. CONCLUSIONS: This study demonstrates that the new nasal interface can improve triggering success rates of pulsed-flow oxygen devices during both nasal and oral breathing scenarios. Further research involving patient trials is recommended to understand the clinical implications of improved pulse triggering.

Virtual simulation in healthcare education: a multi-professional, pan-Canadian evaluation.

BACKGROUND: As we experience a shortage of healthcare providers in Canada, it has become increasingly challenging for healthcare educators to secure quality clinical placements. We evaluated the impact of virtual simulations created for the virtual work-integrated learning (Virtu-WIL) program, a pan-Canadian project designed to develop, test, and offer virtual simulations to enrich healthcare clinical education in Canada. Evaluation was important since the virtual simulations are freely available through creative commons licensing, to the global healthcare community. METHODS: Students self-reported their experiences with the virtual simulations and the impact on their readiness for practice using a survey that included validated subscales. Open-ended items were included to provide insight into the students' experiences. RESULTS: The evaluation included 1715 Nursing, Paramedicine and Medical Laboratory students enrolled in the Virtu-WIL program from 18 post-secondary universities, colleges, and institutions. Results showed most students found the virtual simulations engaging helped them learn and prepare for clinical practice. A key finding was that it is not sufficient to simply add virtual simulations to curriculum, careful planning and applying simulation pedagogy are essential. CONCLUSION: Virtual simulation experiences are increasingly being used in healthcare education. Results from this rigorous, large-scale evaluation identified ways to enhance the quality of these experiences to increase learning and to potentially decrease the number of hours healthcare students need in clinical practice to meet professional competencies. Further research is needed regarding many aspects of virtual simulations and, in particular, curriculum integration and the timing or sequencing of virtual simulations to best prepare students for practice.

A longitudinal study on the impact of simulation on positive deviance through speaking up.

Background: Students reported positive learning outcomes during a simulation study addressing compliance and speaking up. Purpose: Investigate if the impacts of the simulation had a lasting effect on participants after moving into practice. Method: Semi-structured interviews focusing on memory of the study, psychological impacts, educational impacts, professional impacts, and experiences in practice were conducted with Advanced Care Paramedics (3) and Respiratory Therapists (7) between 19 and 24 months after the original study. Discussion: Participants indicated the simulation helped them develop the skill and confidence to speak up, preparing them to speak up in practice. Primary findings included: (i) the importance of experience for speaking up, (ii) the benefit of high-impact simulation, and (iii) the importance of simulation training. Conclusions: Simulation for speaking up should occur early. Conducting high-impact simulations for speaking up is a practical and actionable intervention that appears to enhance confidence, ability, and likelihood of speaking up in practice.

A state-of-the-art review of speaking up in healthcare.

Throughout healthcare, including education, the need for voicing of concern by speaking up is a globally recognized issue that has come to the fore in the last ten years. There has been a rapid growth in the number of review articles on the topic. To prevent diffusion of knowledge and support future research it is necessary to gather the existing knowledge in a single place. The purpose of the present article is to bring together the existing reviews on speaking up to create a source of unified knowledge representing the current "State of the Art" to advance future research and practice. A State-of-the-Art review was conducted to synthesize the existing knowledge on speaking up. Six databases were searched. Fourteen review articles spanning 2012 to 2021 were identified. Five main research questions have been investigated in the literature and five common recommendations for improvement are made, the knowledge across all reviews related to the research questions and recommendations was synthesized. Additionally, simulation-based research was frequently identified as an important though limited method. Further issues in the literature are identified and recommendations for improvement are made. A synthesis was successfully developed: knowledge about speaking up and research related to speaking up is in an emergent state with more shortcomings, questions, and avenues for improvement than certitude. The whys and how of speaking up remain open questions.

Conformity, obedience, and the Better than Average Effect in health professional students.

Background: Compliance, through conformity and obedience to authority, can produce negative outcomes for patient safety, as well as education. To date, educational interventions for dealing with situations of compliance or positive deviance have shown variable results. Part of the challenge for education on compliance may result from disparities between learners' expectations about their potential for engaging in positive deviance and the actual likelihood of engaging in positive deviance. More specifically, students may demonstrate a Better Than Average Effect (BTAE), the tendency for people to believe they are comparatively better than the average across a wide range of behaviours and skills. Methods: Four vignettes were designed and piloted using cognitive interviews, to investigate the BTAE. Conformity and obedience to authority were each addressed with two vignettes. The vignettes were included in a survey distributed to Canadian health professional students across multiple programs at several different institutions during the Winter 2019 semester. Self-evaluation of behaviour was investigated using a one-sample proportion test. Demographic data were investigated using logistic regression to identify predictors of the BTAE. Results: Participants demonstrated the BTAE for expected behaviour compared to peers for situations of conformity and obedience to authority. Age, sex, and program year were identified as potential predictors for exhibiting the BTAE. Conclusions: This study demonstrated that health professional students expect that they will behave better than average in compliance scenarios. Health professional students are not exempt from this cognitive bias in self-assessment. The results have implications for education on compliance, positive deviance, and patient safety.

Contexte: La conformité, par le biais du respect des normes et de l'obéissance à l'autorité, peut avoir des effets négatifs tant pour la sécurité des patients que pour l'éducation des médecins. À ce jour, les interventions éducatives portant sur la conformité ou la déviance positive se sont soldées par des résultats mitigés. Une des difficultés auxquelles se heurte l'enseignement de la conformité provient de l'écart entre les attentes des apprenants quant à la possibilité d'appliquer la déviance positive et la probabilité qu'ils adoptent réellement ce comportement. Plus précisément, les étudiants peuvent faire preuve de supériorité illusoire, c'est-à-dire la tendance à se croire supérieur à la moyenne des gens par rapport à un éventail de comportements et d'habiletés. Méthodes: Quatre vignettes, deux sur la conformité et deux sur l'obéissance à l'autorité, ont été conçues et mises à l'essai dans le cadre d'entretiens cognitifs afin d'étudier la présence du phénomène de supériorité illusoire. Les vignettes faisaient partie d'une enquête menée auprès d'étudiants de différents programmes en sciences de la santé offerts par divers établissements canadiens au cours de la session d'hiver 2019. L'auto-évaluation du comportement a été examinée à l'aide d'un test de proportion pour échantillon unique. Les données démographiques ont été étudiées à l'aide d'une régression logistique pour identifier les prédicteurs de la supériorité illusoire. Résultats: L'effet de supériorité illusoire par rapport aux pairs était présent chez les participants en ce qui concerne le comportement qu'on attend d'eux dans des situations en lien avec la conformité et l'obéissance à l'autorité. L'âge, le sexe et l'année de formation ont été repérés comme prédicteurs potentiels de la manifestation de supériorité illusoire. Conclusions: Cette étude montre que les étudiants en sciences de la santé s'attendent à avoir un comportement supérieur à la moyenne dans les situations où la conformité est en jeu. Ils ne sont pas exempts de ce biais cognitif dans leur auto-évaluation. Les résultats obtenus ont des implications pour l'éducation en matière de conformité, de déviance positive et de sécurité des patients.

A behavioural study of obedience in health professional students.

Interprofessional Education and Collaborative Practice (IPECP) is a field of study suggested to improve team functioning and patient safety. However, even interprofessional teams are susceptible to group pressures which may inhibit speaking up (positive deviance). Obedience is one group pressure that can inhibit positive deviance leading to negative patient outcomes. To examine the influence of obedience to authority in an interprofessional setting, an experimental simulated clinical scenario was conducted with Respiratory Therapy (RT) (n = 40) and Advanced Care Paramedic (ACP) (n = 20) students. In an airway management scenario, it was necessary for students to challenge an authority, a senior anesthesiologist, to prevent patient harm. In a 2 × 2 design cognitive load and an interventional writing task designed to increase positive deviance were tested. The effect of individual characteristics, including Moral Foundations, and displacement of responsibility were also examined. There was a significant effect for profession and cognitive load: RT students demonstrated lower levels of positive deviance in the low cognitive load scenario than students in other conditions. The writing task did not have a significant effect on RT or ACP students' behaviour. The influence of Moral Foundations differed from expectations, In Group Loyalty was selected as a negative predictor of positive deviance while Respect for Authority was not. Displacement of responsibility was influential for some participants thought not for all. Other individual variables were identified for further investigation. Observational analysis of the simulation videos was conducted to obtain further insight into student behaviour in a compliance scenario. Individual differences, including experience, should be considered when providing education and training for positive deviance. Simulation provides an ideal setting to use compliance scenarios to train for positive deviance and for experimentation to study interprofessional team behaviour.

Impact of the stringency of lockdown measures on covid-19: A theoretical model of a pandemic.

BACKGROUND: How effective have lockdowns been at reducing the covid-19 infection and mortality rates? Lockdowns influence contact among persons within or between populations including restricting travel, closing schools, prohibiting public gatherings, requiring workplace closures, all designed to slow the contagion of the virus. The purpose of the present study was to assess the impact of lockdown measures on the spread of covid-19 and test a theoretical model of the covid-19 pandemic employing structural equation modelling. METHODS: Lockdown variables, population demographics, mortality rates, infection rates, and health were obtained for eight countries: Austria, Belgium, France, Germany, Italy, Netherlands, Spain, and the United Kingdom. The dataset, owid-covid-data.csv, was downloaded on 06/01/2020 from: https://github.com/owid/covid-19-data/tree/master/public/data. Infection spread and mortality data were depicted as logistic growth and analyzed with stepwise multiple regression. The overall structure of the covid-19 data was explored through factor analyses leading to a theoretical model that was tested using latent variable path analysis. RESULTS: Multiple regression indicated that the time from lockdown had a small but significant effect (ß = 0.112, p< 0.01) on reducing the number of cases per million. The stringency index produced the most important effect for mortality and infection rates (ß = 0.588,ß = 0.702, ß = 0.518, ß = 0.681; p< 0.01). Exploratory and confirmatory analyses resulted in meaningful and cohesive latent variables: 1) Mortality, 2) Infection Spread, 3) Pop Health Risk, and 4) Health Vulnerability (Comparative Fit Index = 0.91; Standardized Root Mean Square Residual = 0.08). DISCUSSION: The stringency index had a large impact on the growth of covid-19 infection and mortality rates as did percentage of population aged over 65, median age, per capita GDP, diabetes prevalence, cardiovascular death rates, and ICU hospital beds per 100K. The overall Latent Variable Path Analysis is theoretically meaningful and coherent with acceptable fit indices as a model of the covid-19 pandemic.

A case of validity evidence for the Interprofessional Attitudes Scale.

Numerous measures have been developed for the assessment of interprofessional attitudes, including the Interprofessional Attitudes Scale (IPAS). The purpose of this study was to assess, and contribute to, the validity evidence for the IPAS. The IPAS was used in a three-year longitudinal study to collect data from first year health professionals. Three forms of assessment were conducted to accrue validity evidence for the IPAS: Exploratory Factor Analysis, Item Analysis, and analysis using Item Response Theory. Data was collected from 337 participants over three years. Separately, and cumulatively, the Exploratory Factor Analysis, Item Analysis and analysis using Item Response Theory identified issues with the content, response process, internal structure, and consequential validity of the IPAS. The outcomes of the present study call into question the use of the IPAS, and other measures, for the assessment of interprofessional attitudes. The present study contributes several pieces of evidence to the validity of the IPAS and the reevaluation of the use of attitude assessment in interprofessional education.

Longitudinal evaluation of attitudes to interprofessional collaboration: time for a change?

Longitudinal evaluation of interprofessional programming is necessary to understand the impact of interprofessional education (IPE) for collaborative practice. Attitude is one measure of intended behavior. The Interprofessional Attitude Scale (IPAS) was developed as an improved measure to examine the readiness for interprofessional education and collaborative practice. As a means to pilot a protocol for a longitudinal comprehensive evaluation of an interprofessional program with 13 health professional programs in 6 health science faculties, the IPAS was administered over a 3-year period to three cohorts of students. The results of the IPAS indicated no significant differences detected across the 3 years. Although there was a significant difference on the Patient Centredness subscale for Cohorts 2 and 3 the effect size was small. Previous experience in an interprofessional course was a predictor of more positive patient centeredness attitudes, but other IPE experience and years of education were not predictors of any interprofessional attitudes. Students from the Medicine & Dentistry (M&D) faculty ranked significantly lower on the teamwork roles and responsibilities subscale compared to the other faculties, except Rehabilitation Medicine (RM). However, once the outliers in RM were removed, there was a significant difference on this subscale between RM and M&D. This paper outlines the challenges with using the IPAS as part of a comprehensive program evaluation and identifies issues with longitudinal data collection for evaluation with large student cohorts.

Impact of aerosol box on intubation during COVID-19: a simulation study of normal and difficult airways.

PURPOSE: Patients with coronavirus disease (COVID-19) are at risk of requiring mechanical ventilation, and concerns of protecting healthcare workers during aerosol-generating medical procedures has led to the design of the aerosol box. METHODS: We conducted a randomized crossover mannequin-based simulation study to compare airway management with and without the aerosol box. Thirty-five anesthesiology participants and three critical care participants with more than 50 intubations with videolaryngoscopes were recruited. There were four airway simulations with and without the aerosol box (normal, pharyngeal swelling, cervical spine rigidity, and tongue edema). Each participant intubated the mannequin in eight consecutive simulations. The primary outcome of the study was time to intubation. Secondary outcomes included intubation attempts, optimization maneuvers, and personal protective equipment breaches. RESULTS: Mean (standard deviation [SD]) time to intubation overall with the box was 30.9 (23.0) sec, while the time to intubation without the box was 25.1 (12.2) sec (mean difference, 5.8; 95% confidence interval [CI], -2.9 to 14.5). For the normal airway scenario, the mean (SD) time to intubation was 18.6 (3.5) sec for no box and 20.4 (3.3) sec for box (mean difference, 1.8; 95% CI, 0.2 to 3.4). During difficult airway scenarios only, the time to intubation was 34.4 (25.6) sec with the aerosol box and 27.3 (13.2) sec without the aerosol box (mean difference, 7.1; 95% CI, -2.5 to 16.7). There were more intubation attempts, personal protective equipment breaches, and optimization maneuvers during use of the aerosol box. CONCLUSIONS: In this mannequin-based simulation study, the use of the aerosol box increased the time to intubation in some contexts but not others. Further studies in a clinical setting should be conducted to make appropriate modifications to the aerosol box to fully elicit its efficacy and safety prior to implementation in airway guidelines for managing patients with COVID-19.

RéSUMé: OBJECTIF: Les patients atteints de la maladie à coronavirus (COVID-19) courent le risque d'avoir besoin de ventilation mécanique, et les inquiétudes quant à la protection des travailleurs de la santé pendant les interventions médicales générant des aérosols ont motivé la conception d'une boîte pour contenir les aérosols. MéTHODE: Nous avons réalisé une étude de simulation croisée randomisée sur des mannequins afin de comparer la prise en charge des voies aériennes avec et sans boîte pour contenir les aérosols. Trente-cinq anesthésiologistes et trois intensivistes ayant pratiqué plus de 50 intubations avec des vidéolaryngoscopes ont été recrutés. Quatre simulations de voies aériennes avec et sans boîte pour contenir les aérosols ont été évaluées (voies aériennes normales, œdème pharyngé, rigidité de la colonne cervicale et œdème de la langue). Chaque participant a intubé le mannequin dans huit simulations consécutives. Le critère d'évaluation principal de l'étude était le temps nécessaire à l'intubation. Les critères secondaires comprenaient le nombre de tentatives d'intubation, les manœuvres d'optimisation et les bris de stérilité des équipements de protection individuelle. RéSULTATS: Globalement, le temps moyen (écart type [ÉT]) d'intubation avec la boîte était de 30,9 (23,0) sec, alors que le temps d'intubation sans la boîte était de 25,1 (12,2) sec (différence moyenne, 5,8; intervalle de confiance [IC] 95 %, -2,9 à 14,5). Dans la mise en situation simulant des voies aériennes normales, le temps moyen (ÉT) d'intubation était de 18,6 (3,5) sec sans la boîte et 20,4 (3,3) sec avec la boîte (différence moyenne, 1,8; IC 95 %, 0,2 à 3,4). Dans la mise en situation simulant des voies aériennes difficiles seulement, le temps d'intubation était de 34,4 (25,6) sec avec la boîte à aérosol et 27,3 (13,2) sec sans la boîte (différence moyenne, 7,1; IC 95 %, -2,5 à 16,7). Lors de l'utilisation de la boîte pour contenir les aérosols, les tentatives d'intubation étaient plus nombreuses, tout comme les bris de stérilité des équipements de protection individuelle et le nombre de manœuvres d'optimisation. CONCLUSION: Dans cette étude de simulation sur mannequin, l'utilisation de la boîte pour contenir les aérosols a augmenté le temps nécessaire à l'intubation dans certains contextes mais pas dans d'autres. Des études supplémentaires devraient être réalisées dans un cadre clinique pour apporter des modifications adaptées à la boîte pour contenir les aérosols afin d'optimiser son efficacité et la sécurité qu'elle procure avant de l'ajouter aux recommandations de prise en charge des voies aériennes de patients atteints de la COVID-19.

The Critical Thinking Skills of Practicing Family Physicians: A Population-Based Cross-Sectional Study.

BACKGROUND AND OBJECTIVES: Critical thinking (CT) skills are an important aspect of clinical reasoning and diagnosis. The goals of this study were to (1) examine levels of CT skills of practicing family physicians, (2) compare the CT skills of practicing family physicians to family medicine residents, and (3) identify individual variables and practice characteristics predictive of CT skills. . METHODS: We used a population-based, cross-sectional design to compare practicing and resident family physicians and examine the predictors of CT skills in practicing family physicians. Sixty-two practicing family physicians were recruited across Canada. We used data from 59 family medicine residents at a single institution in Canada. We used the California Critical Thinking Skills Test (CCTST) to measure CT skills. We analyzed data using descriptive and univariate analysis, multivariate analysis of variance, and hierarchical multiple linear regression. CT skills were further examined in follow-up analysis using polynomial regression. RESULTS: Residents performed better than practicing physicians on nearly all aspects of CT (P<.005). Age was the strongest predictor of CT skills in practicing physicians (P<.005); CT skills declined with age as a quadratic function (P<.005). CONCLUSIONS: As a group, practicing family physicians exhibited lower scores on the CCTST compared to family medicine residents. CT skills showed a decline with age, accelerating after approximately age 60 years. The results of the study have implications for continuing education and assessment of physicians' clinical skills. Further research is required to better understand what other predictors may be important for CT skills of practicing family physicians.

A multi-method exploratory study of health professional students' experiences with compliance behaviours.

BACKGROUND: Research in healthcare, including students as participants, has begun to document experiences with negative compliance, specifically conformity and obedience. There is a growing body of experimental and survey literature, however, currently lacking is a direct measure of the frequency at which health professional students have negative experiences with conformity and obedience integrated with psychological factors, the outcomes of negative compliance, and students' perceptions. METHODS: To develop empirical knowledge about the frequency of negative compliance and student perceptions during health professional education a multi-methods survey approach was used. The survey was administered to health professional students across ten disciplines at four institutions. RESULTS: The results indicated students regularly experience obedience and conformity and are influenced by impression management and displacement of responsibility. Moral distress was identified as a consistent negative outcome. Student self-reported experiences aligned with the empirical findings. CONCLUSIONS: The findings of the present study demonstrate the pervasiveness of experiences with negative compliance during health professional's education along with some attendant psychological factors. The findings have educational and practical implications, as well as pointing to the need for further integration of social and cognitive psychology in explaining compliance in healthcare. The results are likely generalizable to a population level however replication is encouraged to better understand the true frequency of negative compliance at a health professional population level.

A Study of the Validity of the New MCAT Exam.

PURPOSE: To conduct a study of the validity of the new Medical College Admission Test (MCAT). METHOD: Deidentified data for first- and second-year medical students (185 women, 54.3%; 156 men, 45.7%) who matriculated in 2016 and 2017 to the University of Minnesota Medical School-Twin Cities were included. Of those students, 220 (64.5%) had taken the new MCAT exam and 182 (53.4%) had taken the old MCAT exam (61 [17.9%] had taken both). The authors calculated descriptive statistics and Pearson product moment correlations (r) between new and old MCAT section scores. They conducteda regression analysis of MCAT section scores with Step 1 scores and with preclerkship course performance. They also conducted an exploratory factor analysis (principal component analysis with varimax rotation) of MCAT scores, undergraduate grade point average, Step 1 scores, and course performance. RESULTS: The new MCAT exam section mean score percentiles ranged from 72 to 78 (mean composite score percentile of 80). The old MCAT exam section mean score percentiles ranged from 84 to 88 (mean composite score percentile of 83). The pattern of correlations among and between new and old MCAT exam section scores (range of r: 0.03-0.67; P < .01) provided evidence of both divergent and convergent validities. Backward multiple regression of new MCAT exam section scores and Step 1 scores resulted in a multiple R of .440; the same analysis with Human Behavior course performance as the dependent variable provided a similar solution with the expected sections of the new MCAT exam (multiple R = .502). The factor analysis resulted in 4 cohesive, theoretically meaningful factors: biomedical knowledge, basic science concepts, cognitive reasoning, and general achievement. CONCLUSIONS: This study provided empirical evidence of multiple types of validity for the new MCAT exam.

A Validity Study of the Interprofessional Collaborative Competency Attainment Survey: An Interprofessional Collaborative Competency Measure.

BACKGROUND: In health care, there is a shift toward competency assessment, including in interprofessional collaboration and education. The Interprofessional Collaborative Competency Attainment Survey (ICCAS) has been designed to assess self-reported change in interprofessional competency. METHOD: The current study collects validity evidence for the ICCAS by replicating and expanding previous research, examining internal structure, item functioning, concurrent validity, response process, and consequential validity, including theoretical interpretation of the instrument's application and outcomes. RESULTS: The ICCAS shows good reliability, a single-factor structure, adequate item discrimination, and a moderate concurrent validity. Insight was gained to response process and potential consequences that lend caution to the interpretation of ICCAS results dependent on learner populations. CONCLUSION: The ICCAS has shown stability, making it a potentially useful instrument in assessing self-reported competency but one that should be applied over multiple time points with an awareness of the specific characteristics and knowledge of the sample. [J Nurs Educ. 2019;58(8):454-462.].

Ego identity development in physicians: a cross-cultural comparison using a mixed method approach.

BACKGROUND: The purpose of this study was to examine the career decision-making process of International Medical Graduates (IMGs). There are two main types of IMGs who apply for licensure in Canada. Canadian International Medical Graduates (CIMGs) were Canadian citizens before leaving to study medicine in a foreign country, in comparison to those non-CIMGs who had studied medicine in a foreign country before immigrating to Canada. Given that their motivations for becoming a doctor in Canada may differ, it is important to examine how they decided to become a doctor for each group separately. METHODS: A total of 46 IMGs participated in a semi-structured interview - 20 were CIMGs and 26 were non-CIMGs. RESULTS: An iterative process of content analysis was conducted to categorize responses from five open-ended questions according to the Ego Identity Statuses theory of career decision-making. Event contingency analysis identified a significant difference between CIMGs and non-CIMGs, Fisher's exact test (1) = 18.79, p < .0001. A total of 55% of CIMGs were categorized as identity achieved and 45% as foreclosed; 100% of non-CIMGs were classified as identity foreclosed. CONCLUSION: About half of the Canadian citizens who had studied medicine in a foreign country had explored different careers before making a commitment to medicine, and half had not. No IMGs, however, who studied medicine in another country before immigrating to Canada, had explored various career opportunities before selecting medicine.