Know thy platypus: The insidiousness of cognitive bias.

Cognitive biases are omnipresent in medical practice. The danger of such biases rests largely on the fact that they are difficult to recognize and, by their nature, are positively reinforcing. This paper describes a real experience in which I discovered a classic example of cognitive bias to which I had fallen victim and the lengths I went to in order to preserve the bias. The paper concludes with some cautionary advice and mitigation strategies for educators and practitioners.

Effective accreditation in postgraduate medical education: from process to outcomes and back.

BACKGROUND: The accreditation of medical educational programs is thought to be important in supporting program improvement, ensuring the quality of the education, and promoting diversity, equity, and population health. It has long been recognized that accreditation systems will need to shift their focus from processes to outcomes, particularly those related to the end goals of medical education: the creation of broadly competent, confident professionals and the improvement of health for individuals and populations. An international group of experts in accreditation convened in 2013 to discuss this shift. MAIN TEXT: Participants unequivocally supported the inclusion of more outcomes-based criteria in medical education accreditation, specifically those related to the societal accountability of the institutions in which the education occurs. Meaningful and feasible outcome metrics, however, are hard to identify. They are regionally variable, often temporally remote from the educational program, difficult to measure, and susceptible to confounding factors. The group identified the importance of health outcomes of the clinical milieu in which education takes place in influencing outcomes of its graduates. The ability to link clinical data with individual practice over time is becoming feasible with large repositories of assessment data linked to patient outcomes. This was seen as a key opportunity to provide more continuous oversight and monitoring of program impact. The discussants identified several risks that might arise should outcomes measures completely replace process issues. Some outcomes can be measured only by proxy process elements, and some learner experience issues may best be measured by such process elements: in brief, the "how" still matters. CONCLUSIONS: Accrediting bodies are beginning to view the use of practice outcome measures as an important step toward better continuous educational quality improvement. The use of outcomes will present challenges in data collection, aggregation, and interpretation. Large datasets that capture clinical outcomes, experience of care, and health system performance may enable the assessment of multiple dimensions of program quality, assure the public that the social contract is being upheld, and allow identification of exemplary programs such that all may improve. There remains a need to retain some focus on process, particularly those related to the learner experience.

Back from basics: integration of science and practice in medical education.

CONTEXT: In 1988, the Edinburgh Declaration challenged medical teachers, curriculum designers and leaders to make an organised effort to change medical education for the better. Among a series of recommendations was a call to integrate training in science and clinical practice across a breadth of clinical contexts. The aim was to create physicians who could serve the needs of all people and provide care in a multitude of contexts. In the years since, in the numerous efforts towards integration, new models of curricula have been proposed and implemented with varying levels of success. SCOPE OF REVIEW: In this paper, we examine the evolution of curricular integration since the Edinburgh Declaration, and discuss theoretical advances and practical solutions. In doing so, we draw on recent consensus reports on the state of medical education, emblematic initiatives reported in the literature, and developments in education theory pertinent to the role of integrated curricula. CONCLUSIONS: Interest in integration persists despite 30 years of efforts to respond to the Edinburgh Declaration. We argue, however, that a critical shift has taken place with respect to the conception of integration, whereby empirical models support a view of integration as pertaining to both cognitive activity and curricular structure. In addition, we describe a broader definition of 'basic science' relevant to clinical practice that encompasses social and behavioural sciences, as well as knowledge derived from biomedical science.

What do I do? Developing a competency inventory for postgraduate (residency) program directors.

BACKGROUND: Few new Residency Program Directors (PD) are formally trained for the demands and responsibilities of the leadership aspect of their role. Currently, there are no comprehensive frameworks that describe specific leadership competencies that can inform PD self-reflection or faculty development. METHODS: The authors developed a Postgraduate Program Director Competency Inventory (PPDCI) in order to frame the performance of PDs for a multisource feedback (MSF) program. The development of the PPDCI occurred in five phases which involved: development of an initial inventory, implementation of a key informant survey of national opinion leaders, execution of a validity survey with postgraduate education leaders and committee members and implementation of a further refined inventory with 17 PD and 147 raters as part of a pilot MSF program. OUTCOMES: Five distinct domains of leadership competence were identified which included: Communication and relationship management, leadership, professionalism and self-management, environmental engagement, and management skills and knowledge. The content validity of the PPDCI was endorsed by 85% of the key informants. The validity survey indicated strong endorsement of the PPDCI domains and recognition of its utility for both orientation of new PD as well as a frame for self-assessment. The pilot MSF program yielded a further refined and reduced inventory of 26 items of competence as well as recommendations for its utility. CONCLUSIONS: Use of this leadership inventory has the potential to ensure effective leadership of postgraduate programs.

Conducting Effective Physician Performance Feedback: A Primer for Healthcare Leaders.

Physician performance feedback (PPF) can help physicians gain insight into their practice, to identify areas for improvement, and to implement changes to improve care. There is increasing interest in the use of PPF in Canada. However, little is known about the different types of PPF methods and whether PPF can lead to improved physician performance and patient outcomes. We provide a primer for healthcare leaders interested in doing PPF by reviewing common PPF methods. We then describe our institution's experience with physician multi-source feedback and provide strategies to conduct meaningful PPF.

Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department.

We examined the patient and physician characteristics related to the use and yield of computed tomography pulmonary angiogram (CTPA) for the diagnosis of pulmonary embolism (PE) at a tertiary academic hospital emergency department (ED). A cross-sectional retrospective study was conducted on 835 consecutive ED patients with suspected PE who underwent CTPA. Radiology report data were extracted from our institution's RIS PACS software (Syngo Imaging, Siemens) based on a targeted search of all CTPA reports from 2010 to 2012. Utilization and PE positivity rates of CTPA were calculated and correlated with patient characteristics including age and gender, as well as emergency physician (EP) characteristics including gender, years in practice, and training certification. Acute PE was diagnosed in 17.8 % of patients. A further 32.9 % of the scans were negative for PE but had other clinically significant findings. We found higher utilization rates in female and older patients (p < 0.001), however, without corresponding differences in PE positivity rates compared to their male and younger counterparts. There was a high inter-physician variation in CTPA utilization rate (range 0.21-0.77 scans per 100 patients seen) and PE positivity rate (range 6.7-38.9 %). However, neither rates correlated with EP years of experience (p > 0.15 with cut-offs at 5, 10, and 20 years post-residency), gender (p = 0.59), or training certification (p = 0.56 between EPs certified by the 5-year program of the Royal College of Physicians of Canada versus the 3-year program of the College of Family Physicians of Canada). Our study demonstrated considerable inter-physician variability in the utilization and PE positivity rates of CTPA. These results suggest an opportunity for a more standardized approach to the use of CTPA among EPs at our institution.

Impact of a formal mentoring program on academic promotion of Department of Medicine faculty: a comparative study.

PURPOSE: To evaluate the impact of a formal mentoring program on time to academic promotion and differences in gender-based outcomes. METHODS: Comparisons of time to promotion (i) before and after implementation of a formal mentoring program and (ii) between mentored and non-mentored faculty matched for covariates. Using paired-samples t-testing and mixed repeated measures ANCOVA, we explored the effect of mentor assignment and influence of gender on time to promotion. RESULTS: Promotional data from 1988 to 2010 for 382 faculty members appointed before 2003 were compared with 229 faculty members appointed in 2003 or later. Faculty appointed in 2003 or later were promoted 1.2 years (mean) sooner versus those appointed before 2003 (3.7 [SD = 1.7] vs. 2.5 [SD = 2], p < 0.0001). Regardless of year of appointment, mentor assignment appears to be significantly associated with a reduction in time to promotion versus non-mentored (3.4 [SD = 2.4] vs. 4.4 [SD = 2.6], p = 0.011). Gender effects were statistically insignificant. Post hoc analyses of time to promotion suggested that observed differences are not attributable to temporal effects, but rather assignment to a mentor. CONCLUSIONS: Mentoring was a powerful predictor of promotion, regardless of the year of appointment and likely benefited both genders equally. University resource allocation in support of mentoring appears to accelerate faculty advancement.

Duty hour restrictions: organizational dynamics, systems issues, and the impact on faculty.

The potential impact of resident duty hour restrictions on faculty is likely significant; however, the extent of this impact has still not been well documented. We undertook a narrative review of the literature to determine the magnitude of that potential impact and the nature of the evolving discourse related to faculty members as individuals. The literature provides an inconsistent picture of the impact of duty hour restrictions on faculty. While some studies have reported a significant increase in faculty workload, others suggest that the impact of duty hour restrictions has been minimal. Some papers suggest that duty hour restrictions may fundamentally change the nature of resident-teacher interactions and, as a result, will necessitate significant changes to the way education is delivered. Overall, the majority of issues of concern relate to one of the following: volume and composition of work, impact on faculty career choice, evolving perceptions of residents as learners, and the need to find an appropriate balance between learning and the quality and quantity of patient care. In describing these themes we identify some potential solutions and future directions for reconciling duty hour restrictions with faculty perceptions, anxieties, and desired outcomes.

Multisource feedback and self-assessment of the communicator, collaborator, and professional CanMEDS roles for diagnostic radiology residents.

PURPOSE: To develop a tool for the external and self-evaluation of residents in the Communicator, Collaborator, and Professional CanMEDS roles. METHODS: An academic teaching institution affiliated with 4 major urban hospitals conducted a survey that involved 46 residents and 216 hospital staff members. Residents selected at least 13 external evaluators from different categories (including physicians, nurses or technologists, peers or fellows, and support staff members) from their last 6 months of rotations. The external evaluators and residents answered 4 questions that pertained to each of the 3 CanMEDS roles being assessed. The survey results were analysed for feasibility, variance within and between rater groups, and the relationships between multisource and self-evaluation scores, and between multisource feedback and in-training evaluation report scores. RESULTS: The multisource feedback survey had an overall response rate of 73% with 683 evaluations sent out to 216 unique evaluators. The ratings from different groups of evaluators were only weakly correlated. Residents were most likely to receive their best rating from a collaborating physician and their worst rating from a site secretary or a program assistant. Generally, self-assessment scores were significantly lower than multisource feedback scores. Although there was a strong correlation within the multisource feedback data and within the in-training evaluation report data, there was a weak correlation among the data sets. CONCLUSIONS: Multisource feedback provides useful feedback and scores that relate to critical CanMEDS roles that are not necessarily reflected in a resident's in-training evaluation report. The self-assessment feature of multisource feedback permits a resident to compare the accuracy of his or her assessments to improve their life-long learning skills.

Emergency department overcrowding and long wait times: taking a corporate approach to improving patient flow.

Emergency department (ED) overcrowding and long wait times are major concerns in health systems the world over. Many ED-focused innovations--such as revising staff mix, improving internal processes and exploiting decision-support software--have been implemented to address these complex problems, often with limited success. Beginning in 2008, St. Michael's Hospital in Toronto, which had some of the most challenging ED overcrowding and longest wait times in Ontario, has charted a different course. By taking an organization-wide corporate approach to the challenge of patient flow throughout the hospital, St. Michael's has significantly improved key ED flow metrics for both its admitted and non-admitted patients.

Competence by Design: The Role of High-Stakes Examinations in a Competence Based Medical Education System.

Competency based medical education is developed utilizing a program of assessment that ideally supports learners to reflect on their knowledge and skills, allows them to exercise a growth mindset that prepares them for coaching and eventual lifelong learning, and can support important progression and certification decisions. Examinations can serve as an important anchor to that program of assessment, particularly when considering their strength as an independent, third-party assessment with evidence that they can predict future physician performance and patient outcomes. This paper describes the aims of the Royal College of Physicians and Surgeons of Canada's ("the Royal College") certification examinations, their future role, and how they relate to the Competence by Design model, particularly as the culture of workplace assessment and the evidence for validity evolves. For example, high-stakes examinations are stressful to candidates and focus learners on exam preparation rather than clinical learning opportunities, particularly when they should be developing greater autonomy. In response, the Royal College moved the written examination earlier in training and created an exam quality review, by a specialist uninvolved in development, to review the exam for clarity and relevance. While learners are likely to continue to focus on the examination as an important hurdle to overcome, they will be preparing earlier in training, allowing them the opportunity to be more present and refine their knowledge when discussing clinical cases with supervisors in the Transition to Practice phase. The quality review process better aligns the exam to clinical practice and can improve the educational impact of the examination preparation process.

Integration and timing of basic and clinical sciences education.

BACKGROUND: Medical education has traditionally been compartmentalized into basic and clinical sciences, with the latter being viewed as the skillful application of the former. Over time, the relevance of basic sciences has become defined by their role in supporting clinical problem solving rather than being, of themselves, a defining knowledge base of physicians. METHODS: As part of the national Future of Medical Education in Canada (FMEC MD) project, a comprehensive empirical environmental scan identified the timing and integration of basic sciences as a key pressing issue for medical education. Using the literature review, key informant interviews, stakeholder meetings, and subsequent consultation forums from the FMEC project, this paper details the empirical basis for focusing on the role of basic science, the evidentiary foundations for current practices, and the implications for medical education. FINDINGS: Despite a dearth of definitive relevant studies, opinions about how best to integrate the sciences remain strong. Resource allocation, political power, educational philosophy, and the shift from a knowledge-based to a problem-solving profession all influence the debate. There was little disagreement that both sciences are important, that many traditional models emphasized deep understanding of limited basic science disciplines at the expense of other relevant content such as social sciences, or that teaching the sciences contemporaneously rather than sequentially has theoretical and practical merit. Innovations in integrated curriculum design have occurred internationally. Less clear are the appropriate balance of the sciences, the best integration model, and solutions to the political and practical challenges of integrated curricula. DISCUSSION: New curricula tend to emphasize integration, development of more diverse physician competencies, and preparation of physicians to adapt to evolving technology and patients' expectations. Refocusing the basic/clinical dichotomy to a foundational/applied model may yield benefits in training widely competent future physicians.

Quality evaluation reports: Can a faculty development program make a difference?

BACKGROUND: The quality of medical student and resident clinical evaluation reports submitted by rotation supervisors is a concern. The effectiveness of faculty development (FD) interventions in changing report quality is uncertain. AIMS: This study assessed whether faculty could be trained to complete higher quality reports. METHOD: A 3-h interactive program designed to improve evaluation report quality, previously developed and tested locally, was offered at three different Canadian medical schools. To assess for a change in report quality, three reports completed by each supervisor prior to the workshop and all reports completed for 6 months following the workshop were evaluated by three blinded, independent raters using the Completed Clinical Evaluation Report Rating (CCERR): a validated scale that assesses report quality. RESULTS: A total of 22 supervisors from multiple specialties participated. The mean CCERR score for reports completed after the workshop was significantly higher (21.74 ± 4.91 versus 18.90 ± 5.00, p = 0.02). CONCLUSIONS: This study demonstrates that this FD workshop had a positive impact upon the quality of the participants' evaluation reports suggesting that faculty have the potential to be trained with regards to trainee assessment. This adds to the literature which suggests that FD is an important component in improving assessment quality.

Is there a role for a learner education handover as part of the Medical Council of Canada assessment and licensing process?

The transition from undergraduate medical education (UGME) to postgraduate medical education (PGME) is a time of vulnerability for medical schools, postgraduate residency programs, and most importantly, traineesThere is a disconnect between the UGME and PGME experience. Student information shared by UGME is primarily summative of knowledge and skills; PGME programs are unaware of specific learner accommodation requirements, tailored supervisory needs, or potential professionalism concerns identified during UGMEThis lack of integration between UGME and PGME increases potential risk to learners, postgrad programs and patientsBetter linkages and communication along the education continuum could optimize learning and reduce inefficiency and riskThe Medical Council of Canada (MCC) has asked if there is a role for a learner handover (LH) within their licensing processes; however the intended purpose of an LH must first be determinedA Canadian-based LH referred to as a Learner Education Handover (LEH) model including disclosure of student learning/disability accommodation needs, general health concerns, EDI/religious requirements, professionalism concerns, and recommendations for special focus in residency of specific areas of medical knowledge/skill is described.Findings from beta and pilot testing support the value and feasibility of the LEH model. Fundamental principles are outlined: LEH occurs post-residency matchLEH should be forward facing; focused on ongoing or recurring learner issues and needsLearners must be included in the processImplementation would require participation by all Canadian medical schools and all learnersImplementation challenges include: Ensuring learner safety following information disclosureEngaging UGME DeansProtection of information ensuring a 'need-to-know' status is maintainedIncorporating the LEH into the licensing activity could enable the MCC to support a system that proactively responds to learner needs, optimizes physician performance and promotes safe, high quality patient care.

La transition de la formation médicale prédoctorale (FMPrD) vers la formation médicale postdoctorale (FMPoD) est une période de vulnérabilité pour les facultés de médecine, les programmes de résidence et, surtout, les apprenants.Un gouffre sépare l'expérience de la FMPrD et celle de la FMPoD. L'information sur les étudiants partagée par les programmes de FMPrD consiste principalement en une évaluation sommative de leurs connaissances et habiletés; les programmes de FMPoD ne sont pas renseignés sur les besoins d'accommodement spécifiques et les besoins de supervision sur mesure des apprenants ou sur d'éventuelles préoccupations en lien avec la conduite professionnelle relevés pendant la formation de premier cycle.Ce manque d'intégration entre la FMPrC et la FMPoD augmente les risques pour les apprenants, les programmes de formation postdoctorale et les patients.Des liens plus solides et une meilleure communication tout au long du continuum éducatif pourraient optimiser l'apprentissage et réduire l'inefficacité et les risques.Le Conseil médical du Canada (CMC) a posé la question à savoir s'il y aurait une place pour le transfert d'information sur les apprenants dans le cadre de ses processus d'octroi de licences; toutefois, il faut d'abord déterminer l'objectif visé par le transfert d'information.Nous décrivons un modèle canadien de transfert d'information sur les apprenants, appelé modèle de transfert pour la formation des apprenants (TFA), qui comprend la divulgation des besoins de formation des apprenants et les mesures d'accommodement nécessaires selon leurs difficultés, des préoccupations générales en matière de santé, des exigences en matière d'équité/diversité/inclusion et de religion, des préoccupations en matière de professionnalisme et des recommandations concernant l'accent à mettre sur des domaines spécifiques des connaissances et d'habiletés pendant la résidence.Les résultats des tests bêta et des essais pilotes confirment la valeur et la faisabilité du modèle TFA.Le modèle est fondé sur les principes fondamentaux suivants : Le transfert d'information sur les apprenants a lieu après le jumelage de résidenceLe TFA doit être orienté vers l'avenir; il est axé sur les problèmes et les besoins permanents ou récurrents des apprenantsLes apprenants doivent participer au processusLa mise en œuvre du modèle exigerait la participation de toutes les facultés de médecine et de tous les apprenants au CanadaLa mise en œuvre comprend les défis suivants : Assurer la sécurité des apprenants après la divulgation de l'informationMobiliser les vice-deans des programmes de FMPrCAssurer la protection de l'information en respectant le principe du besoin de savoirL'intégration du transfert d'information sur les apprenants à l'activité d'octroi de licences pourrait permettre au CMC de soutenir un système qui répond de manière proactive aux besoins des apprenants, optimise le rendement des médecins et favorise la sécurité et la qualité des soins aux patients.

The future of medical education: a Canadian environmental scan.

OBJECTIVES: One hundred years after the Flexner report remade medical education in North America, many countries are reviewing the purpose and organisation of medical education. In Canada, a national study is being undertaken to define important issues and challenges for the future of medical education. The objectives of this paper are to describe the process of conducting an empirical environmental scan at a national level, and to present the research findings of this scan. METHODS: Thirty national key informant interviews were conducted, transcribed and coded to identify key themes. Interview data were triangulated with data sourced from 34 commissioned literature reviews and a series of national focus groups. RESULTS: Ten key issues or priorities were identified and used to generate detailed review papers used by the Association of Faculties of Medicine of Canada to create a blueprint for the evolution of medical education. The new priorities have major implications for areas ranging from admissions, curriculum content, educational process and the need to articulate the purpose and responsibilities of medical schools in society. DISCUSSION: This research provides a case study of how an empirical research approach can be used to identify and validate priorities for changes in medical education at a national level. This approach may be of interest in other countries.

Using a Delphi process to establish consensus on emergency medicine clerkship competencies.

BACKGROUND: Currently, there is no consensus on the core competencies required for emergency medicine (EM) clerkships in Canada. Existing EM curricula have been developed through informal consensus or local efforts. The Delphi process has been used extensively as a means for establishing consensus. AIM: The purpose of this project was to define core competencies for EM clerkships in Canada, to validate a Delphi process in the context of national curriculum development, and to demonstrate the adoption of the CanMEDS physician competency paradigm in the undergraduate medical education realm. METHODS: Using a modified Delphi process, we developed a consensus amongst a panel of expert emergency physicians from across Canada utilizing the CanMEDS 2005 Physician Competency Framework. RESULTS: Thirty experts from nine different medical schools across Canada participated on the panel. The initial list consisted of 152 competencies organized in the seven domains of the CanMEDS 2005 Physician Competency Framework. After the second round of the Delphi process, the list of competencies was reduced to 62 (59% reduction). CONCLUSION: This study demonstrated that a modified Delphi process can result in a strong consensus around a realistic number of core competencies for EM clerkships. We propose that such a method could be used by other medical specialties and health professions to develop rotation-specific core competencies.

Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations.

OBJECTIVES Training and practice in medicine are inherently stressful. Research into the effects of acute stressors has revealed significant variability in individual responses to stressors, with performance impairments occurring in those who demonstrate elevated subjective and physiological responses. Cognitive appraisals (subjective assessment of situational demands and available resources) of a stressor have been proposed as a predictor variable in stress responses. However, the relationship between cognitive appraisal and stress responses has not been tested empirically in complex realistic situations. The purpose of this study was to determine the extent to which cognitive appraisal affects a medical trainee's subjective and physiological stress responses to high-acuity simulated clinical situations. METHODS Thirteen emergency medicine and general surgery residents participated in high (HS) and low (LS) stress trauma resuscitation simulations. Subjective (cognitive appraisal and State-Trait Anxiety Inventory [STAI]) and physiological (salivary cortisol) measures were collected at baseline and in response to participation in each scenario. RESULTS Post-scenario STAI scores, cognitive appraisal and cortisol levels were higher in the HS scenario compared with the LS scenario. For the participants who appraised the scenarios as 'threats' (in which the demands outweighed the resources), the ratio of perceived demands to resources was positively correlated with cortisol levels (r = 0.59, p < 0.05) and STAI responses (r = 0.64, p < 0.05). By contrast, for the participants who appraised the scenarios as 'challenges' (in which resources were sufficient to meet the demands), the perceived ratio of demands to resources was not correlated with either the STAI scores or cortisol levels. CONCLUSIONS Subjective appraisals of a situation appear to play an important role in stress responses, which have previously been shown to impair performance. As such, training for high-acuity events should include interventions targeting stress management skills.

International Federation for Emergency Medicine model curriculum for medical student education in emergency medicine.

Currently, there is no internationally recognised, standard curriculum that defines the basic minimum standards for emergency medicine education. To address this, the International Federation for Emergency Medicine convened a committee of international experts in emergency medicine and international emergency medicine development to outline a global curriculum for medical students in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed with a focus on the basic minimum emergency medicine educational content that any medical school should be delivering to its students during their undergraduate years of training. The content is relevant not just for communities with mature emergency medicine systems, but also for developing nations or for nations seeking to expand emergency medicine within current educational structures. It is anticipated that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational milieu, the resources available and the goals of the institutions' educational leadership.

The current utility and future use of the medical student performance record: A survey of perceptions across Canada.

INTRODUCTION: The MSPR is a Canada wide tool that provides aggregate information on MD students' performance during training and used widely as part of PG admissions. This survey study elicits the perceptions of PG admissions stakeholders on the current use and future utility of the MSPR in Canada. METHODS: PG admissions stakeholders across the faculties of medicine were convenience sampled for a 15-question online survey in the fall of 2018. Participants were asked how and when the MSPR is incorporated into the admissions process and perceptions and recommendations for improvement. Data are summarized descriptively and thematically. RESULTS: Responses came from 164 participants across the 17 faculties of medicine. The MSPR was widely used (92%), most commonly in the file review process (52%) for professionalism issues. The majority of responses indicated that MSPRs were not fair for all MD students (60%) and required revision (74%) with greater emphasis required on transparency, professionalism, and narrative comments. DISCUSSION: The results indicate that though MSPRs are widely used in PG admissions their perceived value is limited to a few specific sources of information and to specific parts of the admissions process. There are significant concerns from PG stakeholders on the utility of MSPRs and future changes should align with the needs of these stakeholders while balancing the concerns of students and undergraduate programs.

INTRODUCTION: Le DREM est un outil pancanadien qui procure des renseignements regroupés sur le rendement des étudiants en médecine lors de la formation et il est largement utilisé dans le cadre des admissions post-doctorales. Cette étude par sondage révèle les perceptions des parties prenantes dans les admissions aux études médicales post-doctorales sur l'utilisation actuelle et l'utilité future du DREM au Canada. MÉTHODES: Les parties prenantes impliquées dans les admissions aux études médicales post-doctorales de l'ensemble des facultés de médecine ont été échantillonnés par convenance pour un sondage en ligne de 15 questions à l'automne 2018. Nous avons demandé aux participants comment et quand le DREM est intégré dans le processus d'admission et leurs perceptions et recommandations pour des améliorations. Les données sont résumées de manière descriptive par thèmes. RÉSULTATS: Les réponses proviennent de 164 participants provenant des 17 facultés de médecine. Le DREM a été largement utilisé (92 %) plus communément dans le processus d'examen du dossier (52 %) pour des questions de professionnalisme. La plupart des réponses indiquaient que les DREM n'étaient pas justes pour tous les étudiants en médecine (60 %) et nécessitaient une révision (74 %) avec une attention particulière sur la transparence, le professionnalisme et les commentaires narratifs. DISCUSSION: Les résultats indiquent que bien que les DREM soient largement utilisés dans l'admission aux études médicales post-doctorales, leur valeur perçue est limitée à quelques sources particulières de renseignements et à des parties précises du processus d'admission. Il existe des préoccupations importantes des parties prenantes aux études post-doctorales sur l'utilité des DREM et les changements futurs devraient correspondre aux besoins de ces parties prenantes, tout en équilibrant les préoccupations des étudiants et des programmes de premier cycle.

The competency-based medical education evolution of Canadian emergency medicine specialist training.

Canadian specialist emergency medicine (EM) residency training is undergoing the most significant transformation in its history. This article describes the rationale, process, and redesign of EM competency-based medical education. The rationale for this evolution in residency education includes 1) improved public trust by increasing transparency of the quality and rigour of residency education, 2) improved fiscal accountability to government and institutions regarding specialist EM training, 3) improved assessment systems to replace poor functioning end-of-rotation assessment reports and overemphasis on high-stakes, end-of-training examinations, and 4) and tailored learning for residents to address individualized needs. A working group with geographic and stakeholder representation convened over a 2-year period. A consensus process for decision-making was used. Four key design features of the new residency education design include 1) specialty EM-specific outcomes to be achieved in residency; 2) designation of four progressive stages of training, linked to required learning experiences and entrustable professional activities to be achieved at each stage; 3) tailored learning that provides residency programs and learner flexibility to adapt to local resources and learner needs; and 4) programmatic assessment that emphasizes systematic, longitudinal assessments from multiple sources, and sampling sentinel abilities. Required future study includes a program evaluation of this complex education intervention to ensure that intended outcomes are achieved and unintended outcomes are identified.