Proposing the Community Triad Model to action social accountability in medical schools.

This article is the third in a series exploring drivers of social accountability (SA) in medical schools across Canada. Findings from the two previous articles have highlighted a central relationship between community, students, and faculty at medical schools, and led to the emergence of a new social accountability model- the Community Triad Model (CTM). The CTM proposes an interconnectedness between community, students, faculty, and the broader institution, and the pathways through which community-based learning directly and indirectly influences decision-making in medical institutions. This article explores the relationships between the three arms of the CTM by examining the literature on community engagement and SA, as well as by revisiting popular models and foundational SA reports to garner insights into authentic community engagement in health professions education. While there is an abundance of literature demonstrating the impact of community placements on students, there are limited studies describing the influence of communities on faculty and the broader institution either directly, or indirectly via students. The authors recommend that institutions be more intentional in engaging students and faculty, and learn from their experiences with community to shape curriculum, practices, policies, and culture of the broader institution. This study offers an operational model of SA that is easy to adopt and implement. It intends to demonstrate how the components of the triad (students, faculty/leadership, community) function together in the community engagement and social accountability of medical schools.

Functional knee brace use for 21 h leads to a longer duration to achieve peak vertical ground reaction forces and the removal of the brace after 17.5 h results in faster loading of the knee joint.

PURPOSE: To investigate the landing strategies used after discontinuing and continuing the use of a functional knee brace (FKB) while performing a drop jump. METHODS: Following published methodology and power analysis, 23 uninjured male athletes, mean age of 19.4 ± 3.0 years, performed seven tests, during three test conditions (nonbraced, braced and removed brace or continued brace use), over 6 days of 12 testing sessions (S) for a total of 38.5 h. Each subject was provided with a custom-fitted FKB. This study focuses on the single leg drop jump kinetics during S12 when subjects were randomly selected to remove the FKB after 17.5 h or continued use of FKB. The time to peak vertical ground reaction forces (PVGRF) and PVGRF were recorded on landing in eight trials. RESULTS: After brace removal, a significantly shorter mean time to PVGRF was recorded (9.4 ± 22.9 msec (3.9%), p = 0.005, 95% confidence interval (95% CI): -168.1, 36.1), while continued brace use required a nonsignificant (n.s.) longer mean duration to achieve PVGRF (19.4 ± 53.6 msec (8.9%), n.s., 95% CI: -49.7, 73.4). No significant mean PVGRF difference was found in brace removal (25.3 ± 65.8 N) and continued brace use (25.1 ± 23.0 N). CONCLUSION: Removal of FKB after 17.5 h of use led to a significantly shorter time to achieve PVGRF, while continued brace use for 21 h required a longer duration to achieve PVGRF, suggesting faster and slower knee joint loading, respectively. Understanding the concerns associated with the use of FKB and the kinetics of the knee joint will assist clinicians in counselling athletes about the risks and benefits of using an FKB. LEVEL OF EVIDENCE: Level II.

Creating Socially Accountable Health Conferences: Guidance from Around the World.

BACKGROUND: Very little attention has been given to the social accountability of conferences, either in action or in scholarship, in particular, of scientific conferences. Concerns that have been raised include: (1) Local communities and regions suffer from ecological pressure caused by conferences, (2) There is limited value to the local community, (3) International conferences take place at locations irrelevant to the topics discussed; hence there is no connection with locals, and (4) It has been the observation of the authors that <10% of participants may come from the region where the conference is organized, which makes it challenging to make a "positive societal impact" locally. We conducted a natural experiment investigating the interactions between academia, conference organizers, and community leaders. METHODS: We utilized a case study approach to report on the outcomes of two 2022 annual international conferences that seek to improve community health. We used a mixed-methods approach of surveys and interviews. Thematic analysis was conducted to identify the key themes. RESULTS: We obtained 358 responses from all six World Health Organization regions. Results from both conferences were split into two categories: the why and the how. A strong consensus among participants is that bi-directional learning between conference organizers and local communities leads to shared understanding and mutual goals. The data emphasize that including communities in academic conferences helps us progress forward from intentions toward demonstrating accountability and reporting impact. DISCUSSION: A diversity of perspectives is needed to advance socially accountable health system transformation. Five best practices from conference participants are laid out as a framework to assist in the change: (1) Build trust, (2) provide funding for community member participation, (3) appreciation of local community knowledge, (4) involve the local community in the planning stages, and (5) make the local community part of the conference and learning.

Exploring health coaching and mindfulness as levers for transformation in health: stakeholder perspectives.

BACKGROUND: Health coaching (HC) and mindfulness (MFN) are proven interventions for mobilizing patients' inner resources and are slowly being integrated into public primary care. Since 2015 the medical community in Gibsons BC has integrated physician-led HC and MFN-based programs into team-based care. This exploratory study aimed to understand the mechanisms by which these rural programs helped both patients and clinicians, and to elicit priorities for future study in these fields. METHODS: Using a qualitative participant-engaged constructivist approach in focus groups and large-group graphic facilitation, we elicited perspectives from patients and their physicians during a 1-day event held in September 2018. Thematic analysis of transcripts using Nvivo identified emergent themes that were regularly reviewed with coresearchers, and member checked with participants via online videoconferences held at 6 weeks and 4 months postevent. RESULTS: We identified six main themes relating to the successful implementation of these programs: (i) accessibility and affordability, (ii) offering a toolbox of practical skills, (iii) providing attuned and openhearted care, (iv) generating hope and self-efficacy, (v) experiencing a shared humanity and connection, and (vi) addressing the health of the whole person. CONCLUSION: These themes highlight critical qualities of HC and MFN programs when implemented in a Medicare system. Key features include reducing stigma around mental health through making programs physician-led and a natural part of primary care, enriching accessibility through public funding, and enhancing patient agency through cultivating embodied awareness, self-compassion, and interpersonal skills. These themes inform the next steps to support upscaling these programs to other communities.

Health coaching (HC) and mindfulness (MFN) are proven patient-centered interventions for mobilizing patients' inner resources and changing the trajectories of many chronic physical and psychological conditions. However, though widely available in the private sector, they have been slow to find their way into public primary care in Canada. Since 2015 a rural medical community in BC Canada has integrated physician-led HC and MFN-based programs into primary care. This exploratory study aimed to understand how these programs are working to help both patients and clinicians, providing insights that other communities might use. We elicited perspectives from patient participants and their physicians through focus groups and large-group graphic facilitation during a 1-day event held in September 2018. We identified six themes contributing to successful implementation. Key features include reducing stigma around mental health through making programs publicly accessible and physician-led, and enhancing patient hope and empowerment through cultivating awareness, self-compassion, and interpersonal skills. It also mattered that the facilitators created psychological safety where participants could grow these skills in a nurturing environment, while addressing various dimensions of health. These themes refine our understanding of how these programs can work within public systems to support patient self-management.

Key drivers of social accountability in nine Canadian medical schools.

A social accountability mandate for Canadian medical schools formally emerged in Canada with changes to accreditation standards in 2015. However, how social accountability is defined and operationalized within medical schools has transpired independently. Key enablers of social accountability in Canadian medical schools have been largely unexplored. This paper is the first of a two part series that seeks to explore drivers of social accountability in a sample of Canadian medical schools. Nine key drivers of social accountability emerged from the data including a unified vision, committed leadership, accreditation standards, champions of social accountability, authentic community engagement, community-based learning opportunities, a supportive organizational and governance structure, diversity within medical schools, and measurement of progress and outcomes. This is the first study of its kind to examine what is driving social accountability across Canadian medical schools. An appreciative inquiry approach highlights areas of progress for future work to focus and build upon. This paper presents the findings from part one of the study - exploring the themes emerging from key informant interviews with senior leaders. A second paper will dive into the broader perspectives of faculty, staff and students, to explore more fully the varying perspectives of social accountability within colleges.

AMEE Consensus Statement: Planetary health and education for sustainable healthcare.

The purpose of this Consensus Statement is to provide a global, collaborative, representative and inclusive vision for educating an interprofessional healthcare workforce that can deliver sustainable healthcare and promote planetary health. It is intended to inform national and global accreditation standards, planning and action at the institutional level as well as highlight the role of individuals in transforming health professions education. Many countries have agreed to 'rapid, far-reaching and unprecedented changes' to reduce greenhouse gas emissions by 45% within 10 years and achieve carbon neutrality by 2050, including in healthcare. Currently, however, health professions graduates are not prepared for their roles in achieving these changes. Thus, to reduce emissions and meet the 2030 Sustainable Development Goals (SDGs), health professions education must equip undergraduates, and those already qualified, with the knowledge, skills, values, competence and confidence they need to sustainably promote the health, human rights and well-being of current and future generations, while protecting the health of the planet.The current imperative for action on environmental issues such as climate change requires health professionals to mobilize politically as they have before, becoming strong advocates for major environmental, social and economic change. A truly ethical relationship with people and the planet that we inhabit so precariously, and to guarantee a future for the generations which follow, demands nothing less of all health professionals.This Consensus Statement outlines the changes required in health professions education, approaches to achieve these changes and a timeline for action linked to the internationally agreed SDGs. It represents the collective vision of health professionals, educators and students from various health professions, geographic locations and cultures. 'Consensus' implies broad agreement amongst all individuals engaged in discussion on a specific issue, which in this instance, is agreement by all signatories of this Statement developed under the auspices of the Association for Medical Education in Europe (AMEE).To ensure a shared understanding and to accurately convey information, we outline key terms in a glossary which accompanies this Consensus Statement (Supplementary Appendix 1). We acknowledge, however, that terms evolve and that different terms resonate variably depending on factors such as setting and audience. We define education for sustainable healthcare as the process of equipping current and future health professionals with the knowledge, values, confidence and capacity to provide environmentally sustainable services through health professions education. We define a health professional as a person who has gained a professional qualification for work in the health system, whether in healthcare delivery, public health or a management or supporting role and education as 'the system comprising structures, curricula, faculty and activities contributing to a learning process'. This Statement is relevant to the full continuum of training - from undergraduate to postgraduate and continuing professional development.

Endorsement of clinical practice guidelines: Criteria from the College of Family Physicians of Canada.

OBJECTIVE: To refine the process for endorsement of guidelines and establish the expectations of the College of Family Physicians of Canada (CFPC) regarding the quality and relevance of clinical practice guidelines targeting family physicians and their patients. COMPOSITION OF THE COMMITTEE: Initially, a group of 6 CFPC staff and selected College members reviewed the previous process for endorsement with the aim of providing a new direction, if needed. The work was then assumed by the Guideline and Knowledge Translation Expert Working Group, a purposefully selected group of 9 family physicians from across Canada with expertise in research, evidence, guidelines, knowledge translation, and continuing professional development and education. METHODS: The initial task force reviewed the endorsement process and identified areas for improvement. A draft new process and core criteria for high-quality guidelines were developed. This was approved by the CFPC board. A Guideline and Knowledge Translation Expert Working Group was then formed to further refine the process and the criteria. Multiple resources were used to inform the criteria. The Guideline and Knowledge Translation Expert Working Group will manage the endorsement process of external submitted guidelines, as well as provide high-level guidance to the CFPC regarding in-house guidelines and continuing professional development content. REPORT: This article provides the expectations of the CFPC regarding clinical practice guidelines and describes in detail the process and criteria for endorsement. Key principles include family physician involvement and guideline funding unlikely to introduce bias, with most criteria falling under 4 themed areas: relation to family medicine, CFPC values, patient engagement and decision making, and scientific rigour. The Guideline and Knowledge Translation Expert Working Group will report to the CFPC board at least once a year. It is hoped that this fully transparent process and these criteria will help advance the quality and standards of clinical practice guideline production in Canada. CONCLUSION: A comprehensive but reasonable list has been provided that reflects the best standards and recommendations and is consistent with the CFPC's values while recognizing the landscape of guideline development for its national partners and colleagues. As with all processes, careful consideration and evaluation will be essential.

Education for sustainable healthcare: Leadership to get from here to there.

The current global crises, including climate, COVID-19, and environmental change, requires global collective action at all scales. These broad socio-ecological challenges require the engagement of diverse perspectives and ways of knowing and the meaningful engagement of all generations and stages of personal and professional development. The combination of systems thinking, change management, quality improvement approaches and models, appreciative/strength-based approaches, narratives, storytelling and the strengths of Indigenous knowledges, offer synergies and potential that can set the stage for transformative, strengths-based education for sustainable healthcare (ESH). The need for strong leadership to enact a vision for ESH is outlined here with the intent to enable and nurture the conditions for change, ultimately improving health and well-being across generations.

Building an environmentally accountable medical curriculum through international collaboration.

BACKGROUND: Global environmental change is associated with significant health threats. The medical profession can address this challenge through advocacy, health system adaptation and workforce preparedness. Stewardship of health systems with attention to their environmental impacts can contribute to mitigation of and adaptation to negative health impacts of environmental change. Medical schools have an integral role in training doctors who understand the interdependence of ecosystems and human health. Yet integrating environmental perspectives into busy medical curricula is not a simple task. CONTENT: At the 2016 Association for Medical Education in Europe conference, medical educators, students and clinicians from six continents discussed these challenges in a participatory workshop. Here we reflect on emerging themes from the workshop and how to plan for curricular change. Firstly, we outline recent developments in environmental health and associated medical education. Secondly, we reflect on our process and outcomes during this innovative approach to international collaboration. Thirdly, we present learning objectives which cover core content for environmentally accountable medical curricula, developed through a reflective process of international collaboration integrating current literature and the workshop outcomes. CONCLUSIONS: International collaboration can bring together diverse perspectives and provide critical insights for the inclusion of environmental health into basic education for medical practitioners.

Narratives in family medicine: a global perspective: The Besrour Papers: a series on the state of family medicine in the world.

OBJECTIVE: To explore the development of family medicine postgraduate training in countries with varying levels of resources at different stages of development of the discipline. COMPOSITION OF THE COMMITTEE: Since 2012, the College of Family Physicians of Canada has hosted the Besrour Conferences to reflect on its role in advancing the discipline of family medicine globally. The Besrour Narrative Working Group was conceived in 2012 at the first Besrour Conference. Their mandate was to use narrative and appreciative inquiry to gather stories of family medicine worldwide. The working group comprised members of various academic departments of family medicine in Canada and abroad who attended the conferences. METHODS: A consultation process with our partners from lower-middle-income countries was undertaken from 2012 to 2014. Stories were sought from each global partner institute with ties to Canadian family medicine departments. An appreciative inquiry approach was chosen to elicit narratives. Thematic analysis was used to search for common threads and important elements of success that could serve to inform other initiatives in other nations and, in turn, offer hope for greater effect. REPORT: Sixteen narrative stories have been collected so far. These stories highlight insightful solutions, foresight, perseverance, and ultimately a steadfast belief that family medicine will improve the health system and the care provided to the citizens of each nation. Seventeen themes were elucidated by 3 independent Canadian readers. At a subsequent workshop, these themes were validated by Besrour Centre members from Canada and elsewhere. The linkage between the thematic analysis and the experiences of various schools helps to illustrate both the robustness and the usefulness of the narratives in exploring generalizable observations and the features supporting success in each institute. CONCLUSION: If we are to understand, and contribute to, the development of family medicine throughout the world (a key objective of the Besrour Centre), we must begin to hear each others' stories and search for ways in which our collective story can advance the discipline.

Producing a socially accountable medical school: AMEE Guide No. 109.

Health systems worldwide are confronted with challenges due to increased demand from their citizens, an aging population, a variety of health risks and limited resources. Key health stakeholders, including academic institutions and medical schools, are urged to develop a common vision for a more efficient and equitable health sector. It is in this environment that Boelen and Heck defined the concept of the "Social Accountability of Medical Schools" - a concept that encourages schools to produce not just highly competent professionals, but professionals who are equipped to respond to the changing challenges of healthcare through re-orientation of their education, research and service commitments, and be capable of demonstrating a positive effect upon the communities they serve. Social Accountability calls on the academic institution to demonstrate an impact on the communities served and thus make a contribution for a just and efficient health service, through mutually beneficial partnerships with other healthcare stakeholders. The purpose of this Guide is to explore the concept of Social Accountability, to explain it in more detail through examples and to identify ways to overcome obstacles to its development. Although in the Guide reference is frequently made to medical schools, the concept is equally applicable to all forms of education allied to healthcare.

The Meaning of Patient Experiences of Medically Unexplained Physical Symptoms.

Current diagnostic models in medical practice do not adequately account for patient symptoms that cannot be classified. At the moment, when all known diagnostic possibilities have been excluded, physicians-and patients-confront uncertainty in diagnosis, which gives rise to the label of Medically Unexplained Physical Symptoms (MUPS). This phenomenological study, conducted by two research teams in two geographic locations, sought to explore patients' experiences of prolonged uncertainty in diagnosis. Participants in this study described their experiences with and consequences of MUPS primarily in relation to levels of acuity and acceptance of uncertainty, the latter loosely correlated to length of time since onset of symptoms (the longer the time, the more forbearance participants expressed). We identified three experiential periods including the active search for a diagnosis, living with MUPS, and, finally, acceptance/resignation of their condition. Findings point to the heightened importance of the therapeutic relationship when dealing with uncertainty.

Approaching a global definition of family medicine: The Besrour Papers: a series on the state of family medicine in the world.

OBJECTIVE: To find a common global definition of family medicine. COMPOSITION OF THE COMMITTEE: Since 2012, the College of Family Physicians of Canada has hosted the Besrour Conferences to reflect on its role in advancing the discipline of family medicine globally. The Besrour Papers Working Group, which was struck at the 2013 conference, was tasked with developing a series of papers to highlight the key issues, lessons learned, and outcomes emerging from the various activities of the Besrour collaboration. The working group comprised members of various academic departments of family medicine in Canada and abroad who attended the conferences. METHODS: Searching both definition of family medicine and history of family medicine yields a variety of defining features. Visiting family medicine training programs worldwide highlights this discrepancy. REPORT: It is not an easy task to define family medicine-one of its key attributes is its adaptability to a local context, but this makes aggregation of data challenging. There is a lack of clarity regarding whether family medicine is the same discipline globally and what the core features are that define it. Unifying components of the definition have always included comprehensive care at all life stages and the management of the common illnesses of a particular community. The emerging global emphasis on competency and social accountability demonstrates commitment to the principle that family doctors provide health care for all in the context of the community. Although the competencies are not universal, the fact that family physicians fill in primary care "gaps" and tailor learning strategies to community priorities is a unifying distinction. We argue for a focus on the core competencies that bind us as a discipline. CONCLUSION: Family medicine can be practised in various forms. The unifying elements are the socially accountable responsiveness to local need, the adaptation of existing health infrastructure, and the ongoing development of the skills required to succeed in that role-always grounded in relationships of care. In this way, family medicine will continue to evolve to suit the health needs of communities and health systems.

Validation des lignes directrices de pratique clinique: Critères du Collège des médecins de famille du Canada.

OBJECTIF: Parfaire le processus de validation des lignes directrices et établir les attentes du Collège des médecins de famille du Canada (CMFC) quant à la qualité et à la pertinence des lignes directrices de pratique clinique à l'intention des médecins de famille et de leurs patients. COMPOSITION DU COMITÉ: Au départ, un groupe de 6 personnes, employés et membres choisis du CMFC, ont révisé le précédent processus de validation dans le but de lui donner une nouvelle orientation, au besoin. Le Groupe de travail d'experts sur les lignes directrices et le transfert des connaissances a ensuite pris le relais; ce groupe est composé de 9 médecins de famille sélectionnés avec soin partout au Canada qui sont expérimentés dans les domaines de la recherche, des données probantes, des lignes directrices, du transfert des connaissances, ainsi que du perfectionnement professionnel continu et de l'éducation. MÉTHODOLOGIE: Le groupe de travail initial s'est penché sur le processus de validation et a relevé les domaines pouvant être améliorés. L'ébauche d'un nouveau processus et de critères fondamentaux pour des lignes directrices de bonne qualité a été rédigée et approuvée par le Conseil d'administration du CMFC. Un Groupe de travail d'experts sur les lignes directrices et le transfert des connaissances a ensuite été formé pour peaufiner davantage le processus et les critères. Les critères s'appuient sur plusieurs ressources. Le Groupe de travail d'experts sur les lignes directrices et le transfert des connaissances aura la responsabilité de gérer le processus de validation des lignes directrices externes soumises, ainsi que de fournir au CMFC des conseils de haut niveau sur les lignes directrices internes et le contenu du perfectionnement professionnel continu. RAPPORT: Cet article présente les attentes du CMFC en matière de lignes directrices de pratique clinique, et décrit en détail le processus et les critères de validation. Les principes fondamentaux sont la participation des médecins de famille et le financement des lignes directrices qui est peu susceptible d'introduire un biais, et la plupart des critères s'inscrivent sous 4 thèmes : la relation avec la médecine familiale; les valeurs du CMFC; l'engagement et la prise de décision des patients; et la rigueur scientifique. Le Groupe de travail d'experts sur les lignes directrices et le transfert des connaissances présentera ses résultats au Conseil d'administration du CMFC au moins une fois l'an. L'on souhaite que ce processus complètement transparent et ces critères fassent progresser la qualité et les normes qui régissent la production des lignes directrices de pratique clinique au Canada. CONCLUSION: Une liste exhaustive, mais raisonnable, reflète les meilleures normes et recommandations, et respecte les valeurs du CMFC tout en reconnaissant le contexte de rédaction des lignes directrices pour ses partenaires et ses collègues à l'échelle nationale. Comme c'est le cas pour tous les processus, l'examen et l'évaluation approfondis seront essentiels.

A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills.

SUMMARY: Rural western Canada relies heavily on family physicians with enhanced surgical skills (ESS) for surgical services. The recent decision by the College of Family Physicians of Canada (CFPC) to recognize ESS as a "community of practice" section offers a potential home akin to family practice anesthesia and emergency medicine. To our knowledge, however, a skill set for ESS in Canada has never been described formally. In this paper the Curriculum Committee of the National ESS Working Group proposes a generic curriculum for the training and evaluation of the ESS skill set.

Developing the evidentiary basis for family medicine in the global context: The Besrour Papers: a series on the state of family medicine in the world.

OBJECTIVE: To provide an overview of the main methodologic challenges to finding definitive evidence of the positive effects of family medicine and family medicine training on a global scale. COMPOSITION OF THE COMMITTEE: In 2012, 2013, and 2014, the College of Family Physicians of Canada hosted the Besrour Conferences to reflect on its role in advancing the discipline of family medicine globally. The Besrour Papers Working Group, which was struck at the 2013 conference, was tasked with developing a series of papers to highlight the key issues, lessons learned, and outcomes emerging from the various activities of the Besrour collaboration. The working group comprised members of various academic departments of family medicine in Canada and abroad who attended the conferences. METHODS: We performed a scoping review to determine the methodologic obstacles to understanding the positive effects of family medicine globally. REPORT: The main obstacle to evaluating family medicine globally is that one of its core dimensions and assets is its local adaptability. Family medicine takes on very different roles in different health systems, making aggregation of data difficult. In many countries family medicine competes with other disciplines rather than performing a gatekeeping role. Further, most research that has been conducted thus far comes from industrialized contexts, and patient continuity and its benefits might not be achievable in the short term in developing countries when clinical demands are great. We must find frameworks to permit strengthening the evidentiary basis of the discipline across different contexts without sacrificing its beneficial adaptability. CONCLUSION: We believe that developing family medicine and its attributes is one of the keys to achieving global health. These attributes­including its comprehensiveness, adaptability, and attention to both local and patient needs­are key to advancing global health priorities, but make common evaluative frameworks for the discipline a challenge. The spread of family medicine over the past decades is indirect evidence of its utility, but we need to generate more evidence. We present some of the initial challenges to a broader and more rigorous evaluative framework.