Coaching in Competence by Design: A New Model of Coaching in the Moment and Coaching Over Time to Support Large Scale Implementation.

Coaching is an increasingly popular means to provide individualized, learner-centered, developmental guidance to trainees in competency based medical education (CBME) curricula. Aligned with CBME's core components, coaching can assist in leveraging the full potential of this educational approach. With its focus on growth and improvement, coaching helps trainees develop clinical acumen and self-regulated learning skills. Developing a shared mental model for coaching in the medical education context is crucial to facilitate integration and subsequent evaluation of success. This paper describes the Royal College of Physicians and Surgeons of Canada's coaching model, one that is theory based, evidence informed, principle driven and iteratively and developed by a multidisciplinary team. The coaching model was specifically designed, fit for purpose to the postgraduate medical education (PGME) context and implemented as part of Competence by Design (CBD), a new competency based PGME program. This coaching model differentiates two coaching roles, which reflect different contexts in which postgraduate trainees learn and develop skills. Both roles are supported by the RX-OCR process: developing Relationship/Rapport, setting eXpectations, Observing, a Coaching conversation, and Recording/Reflecting. The CBD Coaching Model and its associated RX-OCR faculty development tool support the implementation of coaching in CBME. Coaching in the moment and coaching over time offer important mechanisms by which CBD brings value to trainees. For sustained change to occur and for learners and coaches to experience the model's intended benefits, ongoing professional development efforts are needed. Early post implementation reflections and lessons learned are provided.

Only as Strong as the Weakest Link: Resident Perspectives on Entrustable Professional Activities and Their Impact on Learning.

Background Core to competency-based medical education (CBME) is the use of frequent low-stakes workplace-based assessments. In the Canadian context, these observations of performance are framed around entrustable professional activities (EPAs). Objective We aimed to explore residents' real-world perspectives of EPAs and their perceived impact on learning, because assessments perceived to be "inauthentic," or not truly reflective of their lived experiences, may interfere with learning. Methods Using constructivist grounded theory, we conducted 18 semistructured interviews in 2021 with residents from all programs that had implemented CBME at one tertiary care academic center in Canada. Participants were recruited via email through respective program administrators. Data collection and analysis occurred iteratively, and categories were identified using constant comparative analysis. Results Residents were strikingly polarized, perceiving EPAs as either a valuable opportunity for professional growth or as an onerous requirement that interfered with learning. Regardless of what view participants held, all perspectives were informed by: (1) the program administration and the perceived messaging from program to residents; (2) faculty assessors and their perceived degree of engagement, or "buy-in" with the EPA system; and ultimately (3) learner behavior. We theorized from these findings that all 3 aspects must be working in tandem for the assessment system to function as intended. Conclusions From the learners' perspective, there exists a dynamic, interdependent relationship between the 3 CBME stakeholders. As such, the perceived value of the EPA assessment system can only be as strong as the weakest link in the chain.

The influence of clinical coaching teams on quality of entrustable professional activity assessments.

Background: Coaching is an important component of workplace-based assessment in competency-based medical education. Longitudinal coaching relationships have been proposed to enhance the trainee-supervisor relationship and promote high-quality assessment. Objective: The objective of this study was to determine the influence of longitudinal coaching relationships on the quality of entrustable professional activity (EPA) assessments. Methods: EPAs (n = 174) completed by emergency medicine (EM) supervisors between July 2020 and June 2021 were extracted and divided into two groups; one group consisted of EPAs completed by supervisors when a longitudinal coaching relationship existed (n = 87) and the other group consisted of EPAs completed by the same supervisors when no coaching relationship existed (n = 87). Three physicians were recruited to rate the EPAs using the Quality of Assessment and Learning (QuAL) score, a previously published measure of EPA quality. An analysis of variance was performed to compare mean QuAL scores between the groups. Linear regression analysis was conducted to examine the relationship between trainee performance (EPA rating) and EPA assessment quality (QuAL score). Results: All raters completed the survey. The mean ± SD QuAL score in the coaching relationship group (3.63 ± 0.91) was higher than the no coaching relationship group (3.51 ± 1.10) but the difference was not statistically significant (p = 0.40). Supervisor was a significant predictor of QuAL score (p = 0.012) and supervisor alone accounted for 26% of the variability in QuAL scores (R2 = 0.26). There was no significant relationship between trainee performance and EPA assessment quality. Conclusions: The presence of a longitudinal coaching relationship did not influence the quality of EPA assessments.

How Emergency Medicine Residents Have Conversations About Life-Sustaining Treatments in Critical Illness: A Qualitative Study Using Inductive Thematic Analysis.

STUDY OBJECTIVE: The inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness. METHODS: Using qualitative methods, semistructured interviews were conducted with a purposive sample of emergency medicine residents in Canada from August to December 2021. Inductive thematic analysis of the interview transcripts was conducted using line-by-line coding, and key themes were identified through comparative analysis. Data collection continued until thematic saturation was reached. RESULTS: Seventeen emergency medicine residents from 9 Canadian universities were interviewed. Two factors guided residents' treatment recommendations (a duty to provide a recommendation and the balance between disease prognosis and patient values). Three factors influenced residents' comfort when making recommendations (time constraints, uncertainty, and moral distress). CONCLUSION: While conducting acute goals-of-care discussions with critically ill patients or their substitute decision makers in the emergency department, residents felt a sense of duty to provide a recommendation informed by an intersection between the patient's disease prognosis and the patient's values. Their comfort in making these recommendations was limited by time constraints, uncertainty, and moral distress. These factors are important for informing future educational strategies.

Does direct observation influence the quality of workplace-based assessment documentation?

Background: A key component of competency-based medical education (CBME) is direct observation of trainees. Direct observation has been emphasized as integral to workplace-based assessment (WBA) yet previously identified challenges may limit its successful implementation. Given these challenges, it is imperative to fully understand the value of direct observation within a CBME program of assessment. Specifically, it is not known whether the quality of WBA documentation is influenced by observation type (direct or indirect). Methods: The objective of this study was to determine the influence of observation type (direct or indirect) on quality of entrustable professional activity (EPA) assessment documentation within a CBME program. EPA assessments were scored by four raters using the Quality of Assessment for Learning (QuAL) instrument, a previously published three-item quantitative measure of the quality of written comments associated with a single clinical performance score. An analysis of variance was performed to compare mean QuAL scores among the direct and indirect observation groups. The reliability of the QuAL instrument for EPA assessments was calculated using a generalizability analysis. Results: A total of 244 EPA assessments (122 direct observation, 122 indirect observation) were rated for quality using the QuAL instrument. No difference in mean QuAL score was identified between the direct and indirect observation groups (p = 0.17). The reliability of the QuAL instrument for EPA assessments was 0.84. Conclusions: Observation type (direct or indirect) did not influence the quality of EPA assessment documentation. This finding raises the question of how direct and indirect observation truly differ and the implications for meta-raters such as competence committees responsible for making judgments related to trainee promotion.

Availability of Emergency Department Wait Times Information: A Patient-Centered Needs Assessment.

INTRODUCTION: Many Emergency Departments (ED) publish wait times; however, the patient perspective in what information is requested and the quantity of information to post is limited. METHODS: We conducted a mixed-methods study at a tertiary care academic center. First, we conducted focus groups of 7 patients. We then generated themes following content analysis to create a patient survey. We administered in-person surveys to patients in ED waiting rooms at sites randomized for survey administration. We used preassigned shifts utilized for even patient perspective representation of the 24 hours-a-day/7 days-a-week service. We included waiting room patients over 18 years of age and excluded patients directly referred to a specialty service or who did not speak French or English. We analyzed survey data using descriptive statistics. RESULTS: We identified nine dominant focus group themes: wait time definition, wait time notification, communication, education, patient expectations, utilization of the ED, patient behaviour, physical comfort, and patient empowerment. Of the 240 patient questionnaires administered, 81.3% of respondents wanted to know ED wait times before hospital arrival hospital and 90.8% wanted ED wait times posted in the waiting room. Website (46.7%) was the most popular choice for publishing wait times outside the ED. Within the ED, patients had no preference regarding display modality, if times were displayed (39.6%). Overall, 76.7% stated that their satisfaction with the ED would be improved if wait times were posted. CONCLUSION: ED patients strongly supported having access to wait time information. Patients believed having wait time information will have a positive impact on their overall ED satisfaction.

Does direct observation happen early in a new competency-based residency program?

BACKGROUND: A key component of competency-based medical education is workplace-based assessment, which includes observation (direct or indirect) of residents. Direct observation has been emphasized as an ideal form of assessment yet challenges have been identified that may limit its adoption. At present, it remains unclear how often direct and indirect observation are being used within the clinical setting. The objective of this study was to describe patterns of observation in an emergency medicine competency-based program 2 years postimplementation. METHODS: Emergency medicine residents (n = 19) recorded the type of observation they received (direct or indirect) following workplace-based entrustable professional activity (EPA) assessments from December 15, 2019, to April 30, 2020. Assessment forms were reviewed and analyzed to describe patters of observation. RESULTS: Assessments were collected on all 19 eligible residents (100% participation). A total of 1,070 EPA assessments were completed during the study period, of which 798 (74.6%) had the type of observation recorded. Of these recorded observations, 546 (68.4%) were directly observed and 252 (31.6%) were indirectly observed. The length of written comments contained within assessments following direct and indirect observation did not differ significantly. There was no significant association between resident gender and observation type or resident stage of training and observation type. Certain EPA assessments showed a clear preference toward either direct or indirect observation. CONCLUSIONS: To the best of our knowledge, this study is the first to report patterns of observation in a competency-based residency program. The results suggest that direct observation can be quickly adopted as the primary means of workplace-based assessment. Indirect observation comprised a sizeable minority of observations and may be an underrecognized contributor to workplace-based assessment. The preference toward either direct or indirect observation for certain EPA assessments suggests that the entrustable professional activity itself may influence the type of observation.

Entrustment Checkpoint: Clinical Supervisors' Perceptions of the Emergency Department Oral Case Presentation.

Phenomenon: The oral case presentation represents a unique method of communication and forms the foundation for trainee-supervisor interactions in the clinical setting. Recently, entrustment has been highlighted as an essential element of trainee-supervisor interactions. Despite the growing body of knowledge concerning entrustment in medical education, how supervisors conceptualize the oral case presentation as a contributor to entrustment decision making during clinical supervision remains unknown. Given their widespread use, oral case presentations may represent a potential tool for future frameworks of workplace-based assessment. This study sought to explore what factors influence supervisors' expectations of oral case presentation content and how the oral case presentation may contribute to entrustment decision making. Approach: Using qualitative methodology, semistructured interviews were conducted from a purposive sample of attending emergency medicine physicians at an academic medical center from 2015 to 2016. Thematic analysis of the semistructured interview transcripts was conducted by 2 investigators using line-by-line coding and constant comparative analysis. Key themes were identified through consensus. Theoretical sampling occurred until thematic saturation was reached. Findings: Twenty-one attending physicians were interviewed. Four factors were found to influence supervisor expectations pertaining to oral case presentation content (trainee level, trainee familiarity, clinical context, and clinical task). Further, the oral case presentation was found to serve as a means of indirect observation and an entrustment check point informing future decisions relating to trainee supervision. Insights: The oral case presentation represents a core activity within the trainee-supervisor relationship in which entrustment plays a central role. Given the numerous factors influencing oral case presentation content, we caution supervisors against relying solely on the oral case presentation as an entrustment check point, as this may lead to inaccurate judgments of trainee competence. We recommend that the oral case presentation be used in conjunction with other means of direct and indirect observation to assist with entrustment decisions relating to trainee supervision.

Atypical Presentation of Right Ventricular Outflow Tract Ventricular Tachycardia.

BACKGROUND: Ventricular tachycardia (VT) in the pediatric population is rare, has a wide differential diagnosis, and can present in numerous ways. In the absence of underlying heart disease, VT is considered idiopathic and is associated with an excellent prognosis. Right ventricular outflow tract ventricular tachycardia (RVOT-VT) represents the most common form of idiopathic VT. The differential diagnosis, mechanism, presentation, management, and prognosis of RVOT-VT in the pediatric population will be discussed. CASE REPORT: We report a case of RVOT-VT that was incidentally discovered in an 11-year-old girl during an emergency department workup for severe headache. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is essential for emergency physicians to have an approach to pediatric VT and appreciate the wide range of potential presentations. Differentiating idiopathic VT, such as RVOT-VT, from more malignant forms of VT can be challenging and requires expert consultation for further diagnostic workup and management.