You can dance if you want to: A case of Sydenham's chorea.

Isolated motor disturbances in the paediatric population are uncommon presentations to the emergency department. Choreiform movements have a broad differential diagnosis and may present insidiously with progressive worsening of asymmetric clumsiness, hypotonia and dysarthria. The incidence of Sydenham's chorea (SC) caused by acute rheumatic fever (ARF) is very rare in developed countries. We report a previously healthy, vaccinated 9-year old male who presented to our ED with intermittent and progressive right sided clumsiness for four weeks. Physical examination findings showed dysdiadokinesis and dysmetric movements of the right side, which varied in intensity and were less pronounced on serial re-examination during the same ED visit. Basic bloodwork, MRI and MRA/V showed no abnormalities, and the patient was discharged home with urgent neurology follow-up. He re-presented to our ED four days later with worsening gait and inability to hold a pencil at school. He was subsequently diagnosed with chorea by the neurology team. The cause of chorea was later determined to be SC, and the patient's throat swab came back positive for group A-beta hemolytic strep (GAS) infection. We explore current literature regarding the various presentations of ARF, differential considerations in acute chorea, and diagnostic studies needed to determine the etiology of acute chorea. With the low incidence of chorea in developed nations, this diagnosis can be easily overlooked. We highlight the importance of this diagnosis, as well as primary and secondary treatment in ARF.

"Maybe it's the first time somebody's been honest with you": exploring how residents reconcile feedback variability.

BACKGROUND: Supervisors in postgraduate medical education may deliver different feedback for the same quality of performance. Residents may struggle to make sense of inconsistent and sometimes contradictory information. We sought to explore how residents experience feedback from different supervisors, how they process inconsistent information, and what factors influence their experiences. METHODS: Eighteen residents participated in semi-structured interviews to explore their perspectives on feedback. Using a constructivist grounded theory approach, we engaged in iterative cycles of data collection and analysis, sampling until theoretical sufficiency was reached. Constant comparative analysis was used to identify and define themes. RESULTS: We identified a central theme of reconciliation, which we defined as the act of processing inconsistent feedback and determining how to engage with it. This reconciliation was informed by the credibility of, and residents' relationship with, supervisors and was achieved through conversations with peers and mentors, observation of other supervisors' behavior toward their performance, and reflection on their own performance. Participants expressed a reluctance to discard feedback, even if they felt it was incongruent with previous feedback or their own self-concept and self-assessment. CONCLUSION: The findings of this study show that while residents are regular consumers of feedback, not all feedback is used equally. Residents actively reconcile sometimes-contradictory feedback and must work to balance a general reluctance to discard feedback, while developing an understanding of its credibility. This work reinforces the importance of pedagogical relationships and identifies that facilitated reflection that explicitly acknowledges feedback inconsistencies may be important in the reconciliation process.

RéSUMé: CONTEXTE: Les superviseurs dans l'enseignement médical postdoctorale peuvent fournir un feedback différent pour la même qualité de performance. Les résidents peuvent avoir du mal à donner un sens à des informations incohérentes et parfois contradictoires. Nous avons cherché à explorer la façon dont les résidents vivent le feedback de différents superviseurs, comment ils traitent les informations incohérentes et quels facteurs influencent leurs expériences. MéTHODES: Dix-huit résidents ont participé à des entretiens semi-structurés pour explorer leur point de vue sur le retour d'information. À l'aide d'une approche fondée sur une théorie constructiviste, nous sommes engagés dans des cycles itératifs de collecte et d'analyse de données, en échantillonnant jusqu'à ce que la suffisance théorique soit atteinte. Une analyse comparative constante a été utilisée pour identifier et définir les thèmes. RéSULTATS: Nous avons identifié un thème central de réconciliation, que nous avons défini comme l'acte de traiter un feedback incohérent et de déterminer comment s'y engager. Cette conciliation a été étayée par la crédibilité des superviseurs et la relation des résidents avec eux, et a été réalisée par le biais de conversations avec des pairs et des mentors, l'observation du comportement d'autres superviseurs à l'égard de leur performance, et la réflexion sur leur propre performance. Les participants ont exprimé une réticence à rejeter les commentaires, même s'ils estimaient qu'ils étaient incompatibles avec les commentaires précédents ou avec leur propre concept de soi et auto-évaluation. CONCLUSION: Les résultats de cette étude montrent que si les résidents sont des consommateurs réguliers de retour d'information, tous les retours d'information ne sont pas utilisés de la même manière. Les résidents réconcilient activement les commentaires parfois contradictoires et doivent s'efforcer de trouver un équilibre entre une réticence générale à rejeter les commentaires, tout en développant une compréhension de sa crédibilité. Ce travail renforce l'importance des relations pédagogiques et identifie que la réflexion facilitée qui reconnaît explicitement les incohérences du feedback peut être importante dans le processus de réconciliation.

Fear, health impacts, and life delays: residents' certification exam year experience.

BACKGROUND: Residency training is associated with risks of burnout and impaired well-being. This may be due to multiple factors, including navigating various transitions. Chief among these is the transition to independent practice which, in Canada, involves a certification exam administered by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. This qualitative study explored the experience of residents in their examination year, including residents impacted by pandemic-related examination postponment, to understand how these experiences may impact residents' well-being. METHODS: Qualitative description methodology was used for this study. Participants were residents and physicians in independent practice from McMaster University and the University of Toronto. In depth, semi-structured, one-on-one interviews were conducted by one of the investigators. Each was transcribed, reviewed, and coded by two members of the investigating team. RESULTS: Five themes were identified. Examinations were perceived to be a significant stressor, and the extent of preparation involved was viewed as a threat to one's physical and mental well-being. Participants identified a culture of fear surrounding the exam, as well as a perception that exam preparation requires significant sacrifice which can exacerbate the impacts of the exam year. Personal and professional supports were identified as important protective factors. CONCLUSION: This study has identified unique challenges in the examination year, and its impact on the well-being of residents immediately before they enter independent practice. Residents also experienced significant learning and a sense of accomplishment through their preparation for the examination. The COVID-19 pandemic had a unique impact on one cohort of residents. This should prompt medical education institutions to examine the support provided to residents, the culture surrounding certification examinations, and mitigation strategies for future examination disruptions.

RéSUMé: CONTEXTE: La formation en résidence est associée à des risques d'épuisement professionnel et de bien-être altéré. Cela peut être dû à plusieurs facteurs, y compris la navigation dans diverses transitions. La principale d'entre elles est la transition vers la pratique indépendante qui, au Canada, implique un examen de certification administré par le Collège royal des médecins et chirurgiens du Canada ou le Collège des médecins de famille du Canada. Cette étude qualitative a exploré l'expérience des résidents au cours de leur année d'examen, y compris les résidents touchés par le report d'examen lié à la pandémie, afin de comprendre comment ces expériences peuvent avoir un impact sur le bien-être des résidents. MéTHODES: Une méthodologie de description qualitative a été utilisée pour cette étude. Les participants étaient des résidents et des médecins en pratique indépendante de l'Université McMaster et de l'Université de Toronto. Des entretiens individuels approfondis et semi-structurés ont été menés par l'un des enquêteurs. Chaque entretien a été transcrit, revu et codé par deux membres de l'équipe d'enquêteurs. RéSULTATS: Cinq thèmes ont été identifiés. Les examens étaient perçus comme un facteur de stress important, et l'ampleur de la préparation était considérée comme une menace pour le bien-être physique et mental. Les participants ont identifié une culture de la peur autour de l'examen, ainsi que la perception que la préparation à l'examen exige des sacrifices importants, ce qui peut exacerber les impacts de l'année de l'examen. Les soutiens personnels et professionnels ont été identifiés comme d'importants facteurs de protection. CONCLUSION: Cette étude a permis d'identifier les défis uniques de l'année d'examen et son impact sur le bien-être des résidents juste avant qu'ils entrent en pratique indépendante. Les résidents ont également fait l'expérience d'un apprentissage important et d'un sentiment d'accomplissement tout au long de leur préparation à l'examen. La pandémie de COVID-19 a eu un impact unique sur une cohorte de résidents. Cela devrait inciter les établissements d'enseignement médical à examiner les soutiens apportés aux résidents, la culture entourant les examens de certification et les stratégies d'atténuation des perturbations futures des examens.

Emergency medicine resident perceptions of simulation-based training and assessment in competence by design.

OBJECTIVES: With the launch of competence by design (CBD) in emergency medicine (EM) in Canada, there are growing recommendations on the use of simulation for the training and assessment of residents. Many of these recommendations have been suggested by educational leaders and often exclude the resident stakeholder. This study sought to explore their experiences and perceptions of simulation in CBD. METHODS: Qualitative data were collected from November 2020 to May 2021 at McMaster University and the University of Toronto after receiving ethics approval from both sites. Eligible participants included EM residents who were interviewed by a trained interviewer using a semi-structured interview guide. All interviews were recorded, transcribed, coded, and collapsed into themes. Data analysis was guided by constructivist grounded theory. RESULTS: A total of seventeen residents participated. Thematic analysis revealed three major themes: 1) impact of CBD on resident views of simulation; 2) simulation's role in obtaining entrustable professional activities (EPAs) and filling educational gaps; and 3) conflicting feelings on the use of high-stakes simulation-based assessment in CBD. CONCLUSIONS: EM residents strongly support using simulation in CBD and acknowledge its ability to bridge educational gaps and fulfill specific EPAs. However, this study suggests some unintended consequences of CBD and conflicting views around simulation-based assessment that challenge resident perceptions of simulation as a safe learning space. As CBD evolves, educational leaders should consider these impacts when making future curricular changes or recommendations.

RéSUMé: OBJECTIFS: Avec le lancement de la compétence par conception (CPC) en médecine d'urgence (MU) au Canada, il existe des recommandations croissantes sur l'utilisation de la simulation pour la formation et l'évaluation des résidents. Beaucoup de ces recommandations ont été suggérées par des leaders éducatifs et excluent souvent la partie prenante résidente. Cette étude visait à explorer leurs expériences et leurs perceptions de la simulation dans la CPC. MéTHODES: Des données qualitatives ont été collectées de novembre 2020 à mai 2021 à l'Université McMaster et à l'Université de Toronto après avoir reçu l'approbation éthique des deux sites. Les participants éligibles étaient des résidents en MU qui ont été interviewés par un interviewer formé à l'aide d'un guide d'entretien semi-structuré. Toutes les interviews ont été enregistrées, transcrites, codées et regroupées en thèmes. L'analyse des données a été guidée par la théorie ancrée constructiviste. RéSULTATS: Au total, dix-sept résidents ont participé. L'analyse thématique a révélé trois thèmes majeurs : (1) l'impact de la CPC sur les opinions des résidents sur la simulation ; (2) le rôle de la simulation dans l'obtention des activités professionnelles confiables (APC) et le comblement des lacunes éducatives ; et (3) des sentiments contradictoires sur l'utilisation de l'évaluation basée sur la simulation à hauts enjeux dans la CPC. CONCLUSIONS: Les résidents en MU soutiennent fortement l'utilisation de la simulation dans la CPC et reconnaissent sa capacité à combler les lacunes éducatives et à remplir des APC spécifiques. Cependant, cette étude suggère quelques conséquences imprévues de la CPC et des opinions divergentes sur l'évaluation basée sur la simulation qui remettent en question les perceptions des résidents de la simulation comme un espace d'apprentissage sécuritaire. À mesure que la CPC évolue, les leaders éducatifs devraient tenir compte de ces impacts lorsqu'ils apportent des changements ou des recommandations curriculaires futurs.

Transition to practice: Evaluating the need for formal training in supervision and assessment among senior emergency medicine residents and new to practice emergency physicians.

OBJECTIVES: Emergency medicine residents may be transitioning to practice with minimal training on how to supervise and assess trainees. Our study sought to examine: 1) physician comfort with supervision and assessment, 2) what the current training gaps are within these competencies, and 3) what barriers or enablers might exist in implementing curricular improvements. METHODS: Qualitative data were collected in two phases through individual interviews from September 2016 to November 2017, at the University of Toronto and McMaster University after receiving ethics approval from both sites. Eligible participants were final year emergency medicine residents, residents pursuing an enhanced skills program in emergency medicine, and attendings within their first 3 years of practice. A semi-structured interview guide was developed and refined after phase one, to reflect content identified in the first set of interviews. All interviews were recorded, transcribed, coded, and collapsed into themes. Data analysis was guided by constructivist grounded theory. RESULTS: A thematic analysis revealed five themes: 1) Supervision and assessment skills were acquired passively through modelling, 2) the training available in these areas is variably used, creating a diversity of comfort levels, 3) competing priorities in the emergency department represent significant barriers to improving supervision and assessment; 4) providing negative feedback is difficult and often avoided; and 5) competence by design will act as an impetus for formal curriculum development in these areas. CONCLUSIONS: As programs transition to competence by design, there will be a need for formal training in supervision and assessment, with a focus on negative feedback, to achieve a standardized level of competence among emergency physicians.

Emergency medicine resident wellness: Lessons learned from a national survey.

OBJECTIVES: Emergency medicine (EM) residents face many challenges during residency. Given the negative effects of residency training and the paucity of information on EM resident wellness experiences, we conducted a national survey to characterize the current landscape of Canadian EM resident wellness. METHODS: A cross-sectional study of Canadian EM residents was done using an online survey created by a Canadian Association of Emergency Physicians Resident Section working group on wellness. Surveys were sent to chief residents in Canadian EM residency programs accredited by either the Royal College of Physicians and Surgeons of Canada (RCPSC) or the College of Family Physicians of Canada (CFPC) in English and French. RESULTS: Thirty-one EM programs were contacted (14 RCPSC and 17 CFPC), and 216 (42%) responses were collected. A multitude of negative wellness impacts were noted, including falling asleep while driving and motor vehicle collisions post-night or during a 24-hour call shift. Moreover, experiences included verbal, physical, and sexual harassment, and reports of low mood and suicidal ideation. Wellness supports were not always accessed after negative incidents. Residents reported deficits in formal wellness instruction, with support for formal EM program wellness time. CONCLUSIONS: Canadian EM residents face a multitude of psychosocial and physical wellness challenges, while supports may not be adequate. Opportunities exist to further investigate resident wellness with validated tools, engage stakeholders, and advance the EM resident wellness agenda.