Preparing for CBME: How often are faculty observing residents?

BACKGROUND: The Royal College of Physicians and Surgeons of Canada officially launched 'Competence by Design' in July 2017, moving from time-based to outcomes-based training. Transitioning to competency-based medical education (CBME) necessitates change in resident assessment. A greater frequency of resident observation will likely be required to adequately assess whether entrustable professional activities have been achieved. PURPOSE: Characterize faculty and resident experiences of direct observation in a single paediatric residency program, pre-CBME implementation. Qualitatively describe participants' perceived barriers and incentives to participating in direct observation. METHODS: Surveys were sent to paediatric residents and faculty asking for demographics, the frequency of resident observation during an average 4-week rotation, perceived ideal frequency of observation, and factors influencing observation frequency. Descriptive data were analyzed. Institutional research ethics board approval was received. RESULTS: The response rate was 54% (34/68 faculty and 16/25 residents). When asked the MAXIMUM frequency FACULTY observed a resident take a history, perform a physical examination, or deliver a plan, the median faculty reply was 1, 2, and 3, for outpatient settings and 0, 1, and 2, for inpatient settings. The median RESIDENT reply was 2, 4, and 10 for outpatient settings and 1, 2, and 20 for inpatient settings. When asked the MINIMUM frequency for each domain, the median FACULTY and RESIDENT reply was 0, except for delivering a plan in the inpatient setting. Faculty reported observing seniors delivering the plan more frequently than junior residents. Faculty and resident median replies for how frequently residents should be observed for each domain were the same, three to four, three to four, and five to six times. Four per cent of faculty reported regularly scheduling observations, and 77% of residents regularly ask to be observed. The most common barriers to observation were too many patients to see and both faculty and residents were seeing patients at the same time. Most faculty and resident responders felt that observation frequency could be improved if scheduled at the start of the rotation; faculty were provided a better tool for assessment; and if residents asked to be observed. CONCLUSIONS: This study provides baseline data on how infrequent faculty observation is occurring and at a frequency lower than what faculty and residents feel is necessary. The time needed for observation competes with clinical service demands, but better scheduling strategies and assessment tools may help.

Implementation and evaluation of a curriculum on the assessment and treatment of disruptive behaviour disorders.

Disruptive behaviour disorders (DBDs)-which can include or be comorbid with disorders such as attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder and disruptive mood dysregulation disorder-are commonly seen in paediatric practice. Given increases in the prescribing of atypical antipsychotics for children and youth, it is imperative that paediatric trainees in Canada receive adequate education on the optimal treatment of DBDs. We describe the development, dissemination, and evaluation of a novel paediatric resident curriculum for the assessment and treatment of DBDs in children and adolescents. Pre-post-evaluation of the curriculum showed improved knowledge in participants.

Implementation of a resident-led patient safety curriculum.

The Royal College of Physicians and Surgeons of Canada has made Quality Improvement and Patient Safety (QIPS) a priority in residency education, however, implementation is limited by the heterogeneity of previously published curricula. We created a longitudinal resident-led patient safety (PS) curriculum using relatable, real-life PS incidents (PSIs) and an analysis framework.Implementation was feasible, well received by residents and demonstrated significant improvement in residents' PS knowledge,skills, and attitudes. Our curriculum built a culture of PS within a pediatric residency program, promoted engagement in QIPS practices early in training, and filled a gap in the current curriculum teaching.

Le Collège royal des médecins et chirurgiens du Canada a fait de la sécurité des patients et de l'amélioration de la qualité (SPAQ) une priorité dans la formation des résidents, mais l'atteinte de ces objectifs est limitée par l'hétérogénéité des programmes de formation existants. Nous avons co-construit avec des residents un programme de formation longitudinal sur la sécurité des patients (SP), à partir d'incidents réels et pertinents liés à la SP et d'un cadre d'analyse. Facile à réaliser et bien accueillie par les résidents, la formation a été suivie d'une amélioration marquée des connaissances, des compétences et des attitudes des résidents en matière de SP. Notre formation a permis de créer une culture de la SP au sein d'un programme de résidence en pédiatrie, de promouvoir l'adoption de pratiques qui favorisent la SPAQ dès le début de la residence et de combler ainsi une lacune des programmes actuels.

Adolescent interviewing skills: effect of feedback.

BACKGROUND: Communicating with adolescent patients can be challenging. Our study assessed the effect of structured feedback following a standardised patient (SP) encounter on postgraduate year-1 (PGY1) residents' adolescent-specific communication skills. Communicating with adolescent patients can be challenging METHODS: A two-group, prospective, double-blind randomised control study design was employed. Measures were taken before and after the intervention. PGY1 residents conducted a 30-minute interview with an SP adolescent-mother pair, who then individually scored the resident's performance using the validated Structured Communication Adolescent Guide (SCAG). PGY1s were randomised to receive either structured feedback following the interview (feedback group) or no feedback (no feedback group). All residents completed a second interview 4-6 weeks later. Scores were analysed using unpaired t-tests. RESULTS: Thirty-eight residents completed both interviews. The mean total-item and mean global scores for the first interview did not differ significantly between the feedback (n = 21) and no-feedback group (n = 17). The mean total-item scores for the feedback group [first interview: 34.19 ± 10.19 (adolescent); 36.33 ± 9.77 (mother)] improved significantly for the second interview [45.17 ± 6.22 (adolescent); 44.71 ± 6.72 (mother); p = 0.002 and 0.003, respectively]. The mean global scores also improved significantly from the first interview [27.00 ± 6.49 (adolescent); 27.47 ± 6.50 (mother)] to the second interview [34.05 ± 3.30 (adolescent); 31.19 ± 3.85 (mother); p = 0.001 and 0.03, respectively]. No significant improvement in the mean total-item or mean global rating was observed in the no feedback group. CONCLUSIONS: Structured feedback following a single adolescent and mother SP encounter resulted in significant improvement in the adolescent-specific communication skills of PGY1s in performing an adolescent interview.

R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency.

BACKGROUND: Feedback is increasingly seen as a collaborative conversation between supervisors and learners, where learners are actively and reflectively engaged with feedback and use it to improve. Based on this, and through earlier research, we developed an evidence- and theory-informed, 4-phase model for facilitating feedback and practice improvement-the R2C2 model (relationship, reaction, content, coaching). OBJECTIVE: Our goal was to explore the utility and acceptability of the R2C2 model in residency education, specifically for engaging residents in their feedback and in using it to improve, as well as the factors influencing its use. METHODS: This qualitative study used the principles of design research. We recruited residents and their supervisors in 2 programs, internal medicine and pediatrics. We prepared supervisors to use the R2C2 model during their regular midrotation and/or end-of-rotation feedback sessions with participating residents to discuss their progress and assessment reports. We conducted debriefing interviews with supervisors and residents after each session. We analyzed transcripts as a team using template and content analysis. RESULTS: Of 61 residents, 7 residents (11%) participated with their supervisors (n = 5). Schedules and sensitivity to feedback prevented broader enrollment. Supervisors found the structured R2C2 format useful. Residents and supervisors reported that the coaching phase was novel and helpful, and that the R2C2 model engaged both groups in collaborative, reflective, goal-oriented feedback discussions. CONCLUSIONS: Participants found that using the R2C2 model enabled meaningful feedback conversations, identification of goals for improvement, and development of strategies to meet those goals.

Skills for Interviewing Adolescent Patients: Sustainability of Structured Feedback in Undergraduate Education on Performance in Residency.

BACKGROUND: Effective adolescent (10 to 19 years) interviewing by physicians is an essential skill that many trainees can find challenging. OBJECTIVE: We assessed whether structured adolescent interviewing using standardized patients (SPs) and feedback in undergraduate medical education (UME) has a sustained effect on residents' skills. METHODS: Postgraduate year (PGY) 1 residents conducted interviews with a SP adolescent-mother pair. The SPs independently scored each PGY-1 interview using the structured communication adolescent guide (SCAG). Unpaired t tests were conducted comparing "Total-Item" and "Global" scores of PGY-1s who received structured SP adolescent interviewing with feedback in UME ("structured training" group) to those who had not ("no structured training" group). RESULTS: PGY-1s in the structured training group (n = 23) received significantly higher mean Total-Item scores from both the SP adolescent (40.78 ± 7.04 and 32.41 ± 10.12, respectively; P = .001) and the SP mother (40.48 ± 7.90 and 33.34 ± 10.90, respectively; P = .01) than those without structured training (n = 29). Statistically significant results favoring PGY-1s with prior training were also seen with the SP adolescent and mother total Global SCAG scores. CONCLUSIONS: Structured training in adolescent interviewing with SPs and feedback in UME appears to have a sustained effect on residents' adolescent interviewing skills. PGY-1s will interview adolescents and may benefit from structured adolescent SP interviewing with feedback, especially individuals who did not have this experience during their medical school training.

Youth health care utilization in Nova Scotia: what is the role of age, sex and socio-economic status?

OBJECTIVE: Youth have distinct health care needs that are not always met within a framework designed for children or adults. In Canada, little attention has been given to how youth utilize health care services and limited data are available. The aim of this study was to identify whether age, sex, socio-economic status (SES) and geographic location were significant mediators of youth health care utilization in Nova Scotia. METHODS: The NSYOUTHS database comprises health care utilization information for all youth aged 12 to 24 years, resident in Nova Scotia between 1997 and 2007. We calculated health care utilization rates by provider, stratified by sex, age, SES, urban/rural residence and year. Negative binomial regression was used to model the variation in health care utilization by sex, SES and urban/rural location. RESULTS: Health care utilization declined over time and varied by age. Females were more frequent users of services. Youth from lower SES areas had fewer family physician contacts but more outpatient, emergency and inpatient contacts compared to those from higher SES areas. Rural residents had fewer family physician and emergency contacts but more outpatient contacts than youth from urban areas. Ten percent of the youth were responsible for 32% of all health care contacts, whereas 11% had no health care contacts. CONCLUSION: Specific subgroups, including youth from rural areas and of lower SES, utilize health care services differently than other youth. The challenge is to provide health care that is responsive to the needs of this heterogeneous population. Meeting this challenge requires accurate information on youth health care utilization.