The McMaster Narrative Comment Rating Tool: Development and Initial Validity Evidence.

CONSTRUCT: The McMaster Narrative Comment Rating Tool aims to capture critical features reflecting the quality of written narrative comments provided in the medical education context: valence/tone of language, degree of correction versus reinforcement, specificity, actionability, and overall usefulness. BACKGROUND: Despite their role in competency-based medical education, not all narrative comments contribute meaningfully to the development of learners' competence. To develop solutions to mitigate this problem, robust measures of narrative comment quality are needed. While some tools exist, most were created in specialty-specific contexts, have focused on one or two features of feedback, or have focused on faculty perceptions of feedback, excluding learners from the validation process. In this study, we aimed to develop a detailed, broadly applicable narrative comment quality assessment tool that drew upon features of high-quality assessment and feedback and could be used by a variety of raters to inform future research, including applications related to automated analysis of narrative comment quality. APPROACH: In Phase 1, we used the literature to identify five critical features of feedback. We then developed rating scales for each of the features, and collected 670 competency-based assessments completed by first-year surgical residents in the first six-weeks of training. Residents were from nine different programs at a Canadian institution. In Phase 2, we randomly selected 50 assessments with written feedback from the dataset. Two education researchers used the scale to independently score the written comments and refine the rating tool. In Phase 3, 10 raters, including two medical education researchers, two medical students, two residents, two clinical faculty members, and two laypersons from the community, used the tool to independently and blindly rate written comments from another 50 randomly selected assessments from the dataset. We compared scores between and across rater pairs to assess reliability. FINDINGS: Single and average measures intraclass correlation (ICC) scores ranged from moderate to excellent (ICCs = .51-.83 and .91-.98) across all categories and rater pairs. All tool domains were significantly correlated (p's <.05), apart from valence, which was only significantly correlated with degree of correction versus reinforcement. CONCLUSION: Our findings suggest that the McMaster Narrative Comment Rating Tool can reliably be used by multiple raters, across a variety of rater types, and in different surgical contexts. As such, it has the potential to support faculty development initiatives on assessment and feedback, and may be used as a tool to conduct research on different assessment strategies, including automated analysis of narrative comments.

A History of Musculoskeletal Medicine and Its Place and Progress in Undergraduate Medical Education.

Musculoskeletal diseases are responsible for some of the most prevalent conditions affecting population health in the world. Despite the prevalence of these conditions, musculoskeletal medicine has a fraught history within the world of undergraduate medical education. We review the origins of musculoskeletal medicine, its evolution in undergraduate medical education, and progress that has been made over the last decade as a result of global initiatives such as the Bone and Joint Decade. Understanding the history of musculoskeletal medicine is essential to contextualizing the problems that exist today and creating comprehensive solutions to fill the gaps that persist in musculoskeletal curricula.

Comparing the Quality of Narrative Comments by Rotation Setting.

OBJECTIVE: To investigate the effect of rotation setting on trainee-directed narrative comments within a Canadian General Surgery Residency Program. The primary outcome was to use the McMaster Narrative Comment Rating Scale (MNCRS) to evaluate the quality of narrative comments across five domains: valence of language, degree of correction versus reinforcement, specificity, actionability and overall usefulness. As distributed medical education in the postgraduate training context becomes more prevalent, delineating differences in feedback between various sites will be imperative, as it may affect how narrative comments are interpreted by clinical competency committee (CCC) members. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of 2,469 assessments obtained between July 1, 2014 and May 5, 2019 from the General Surgery Residency Program at the University of British Columbia (UBC) was conducted. Narrative comments were rated using the McMaster Narrative Comment Rating Scale (MNCRS), a validated instrument for evaluating the quality of narrative comments. A repeated measures Analysis of Variance (ANOVA) was conducted to explore the impact of rotation setting, academic, urban tertiary, distributed urban, and distributed rural on the quality of narrative feedback. RESULTS: Overall, the quality of the narrative comments varied substantially between and within rotation settings. Academic sites tended to provide more actionable comments (p = 0.01) and more corrective versus reinforcing comments, compared with other sites (p's < 0.01). Comments produced by the urban tertiary rotation setting were consistently lower in quality across all scale categories compared with other settings (p's < 0.01). CONCLUSION: The type of rotation setting has a significant effect on the quality of faculty feedback for trainees. Faculty development on the provision of feedback is necessary, regardless of rotation setting, and should appropriately combine rotation-specific needs and overarching program goals to ensure trainees and clinical competence committees receive high quality narrative.

Competence committees: The steep climb from concept to implementation.

INTRODUCTION: Competence committees (CCs) are groups of educators tasked with reviewing resident progress throughout their training, making decisions regarding the achievement of Entrustable Professional Activities and recommendations regarding promotion and remediation. CCs have been mandated as part of competency-based medical education programmes worldwide; however, there has yet to be a thorough examination of the implementation challenges they face and how this impacts their functioning and decision-making processes. This study examined CC implementation at a Canadian institution, documenting the shared and unique challenges that CCs faced and overcame over a 3-year period. METHODS: This study consisted of three phases, which were conceptually and analytically linked using Moran-Ellis and colleagues' notion of 'following a thread.' Phase 1 examined the early perceptions and experiences of 30 key informants using a survey and semi-structured interviews. Phase 2 provided insight into CCs' operations through a survey sent to 35 CC chairs 1-year post-implementation. Phase 3 invited 20 CC members to participate in semi-structured interviews to follow up on initial themes 2 years post-implementation. Detailed observation notes from 16 CC meetings across nine disciplines were used to corroborate the findings from each phase. RESULTS: Response rates in each phase were 83% (n = 25), 43% (n = 15) and 60% (n = 12), respectively. Despite the high degree of support for CCs among faculty and resident members, several ongoing challenges were highlighted: adapting to programme size, optimising membership, engaging residents, maintaining capacity among members, sharing and aggregating data and developing a clear mandate. DISCUSSION: Findings of this study reinforce the importance of resident engagement and information sharing between disciplines. Challenges faced by CCs are discussed in relation to the existing literature to inform a better understanding of group decision-making processes in medical education. Future research could compare implementation practices across sites and explore which adaptations lead to better or worse decision-making outcomes.

The role of gender in the decision to pursue a surgical career: A qualitative, interview-based study.

BACKGROUND: Previous literature has explored the underrepresentation of women in surgery. However, this research has often been quantitative or limited by considering only the perspectives and experiences of women at more advanced career stages. Here, we use a qualitative methodology and a sample of women and men across the career continuum to identify the role that gender plays in the decision to pursue a surgical career. METHODS: We audio-recorded and transcribed semi-structured interviews conducted with 12 women and 12 men ranging in their level of medical training from medical students to residents to staff surgeons. We used Braun and Clarke's six-step approach to thematic analysis to analyze the data, maintaining trustworthiness and credibility by employing strategies including reflexivity and participant input. RESULTS: Our findings suggested that the characteristics of surgery and early exposure to the profession served as important factors in participants' decisions to pursue a surgical career. Although not explicitly mentioned by participants, each of these areas may implicitly be gendered. Gender-based factors explicitly mentioned by participants included the surgical lifestyle and experiences with gender discrimination, including sexual harassment. These factors were perceived as challenges that disproportionately affected women and needed to be overcome when pursuing a surgical career. CONCLUSIONS: Our findings suggest that gender is more likely to act as a barrier to a career in surgery than as a motivator, especially among women. This suggests a need for early experiences in the operating room and mentorship. Policy change promoting work-life integration and education to target gender discrimination is also recommended.

CONTEXTE: Des publications antérieures ont exploré la sous-représentation des femmes en chirurgie. Toutefois, cette recherche a souvent été quantitative ou limitée en considérant uniquement les perspectives et expériences de femmes à des stades plus avancés de leur carrière. Ici, nous utilisons une méthodologie qualitative et un échantillon de femmes et d'hommes a des stades différents de leur carrière pour établir le rôle que le genre joue dans la décision de poursuivre une carrière en chirurgie. MÉTHODES: Nous avons enregistré et transcrit des entrevues semi-structurées menées avec douze femmes et douze hommes, dont la formation médicale variait d'étudiants en médecine à résidents et à chirurgiens membres du personnel hospitalier. Nous avons utilisé l'analyse thématique en six étapes de Braun et Clarke pour analyser les données, conservant la fiabilité et la crédibilité en utilisant des stratégies qui comprenaient la réflexivité et les commentaires des participants. RÉSULTATS: Nos résultats suggèrent que les caractéristiques de la chirurgie et d'une exposition précoce à la profession constituaient des facteurs importants dans la décision des participants de poursuivre une carrière en chirurgie. Bien que ce n'était pas explicitement mentionné par les participants, chacun de ces domaines peut être implicitement sexospécifique. Les facteurs fondés sur le genre mentionnés explicitement par les participants comprenaient le mode de vie chirurgical et les expériences avec la discrimination fondée sur le sexe, y compris le harcèlement sexuel. Ces facteurs étaient perçus comme des obstacles qui touchaient de manière disproportionnée les femmes et qui devaient être surmontés dans la poursuite d'une carrière en chirurgie. CONCLUSIONS: Nos résultats suggèrent que le genre est plus susceptible d'agir comme un obstacle à une carrière en chirurgie que comme facteur de motivation, plus particulièrement chez les femmes. Cela suggère un besoin pour des expériences précoces dans la salle d'opération et le mentorat. Un changement dans la politique favorisant l'intégration travail-vie et une éducation pour cibler la discrimination fondée sur le genre est également recommandé.

Use of the KT-MCC strategy to improve the quality of decision making for multidisciplinary cancer conferences: a pilot study.

BACKGROUND: Multidisciplinary Cancer Conferences (MCCs) are increasingly used to guide treatment decisions for patients with cancer, though numerous barriers to optimal MCC decision-making quality have been identified. We aimed to improve the quality of MCC decision making through the use of an implementation bundle titled the KT-MCC Strategy. The Strategy included use of discussion tools (standard case intake tool and a synoptic discussion tool), workshops, MCC team and chair training, and audit and feedback. Implementation strategies were selected using a theoretically-rooted and integrated KT approach, meaning members of the target population (MCC participants) assisted with the design and implementation of the intervention and strategies. We evaluated implementation quality of the KT-MCC Strategy and initial signals of impact on decision making quality. METHODS: This was a before-and-after study design among 4 MCC teams. Baseline data (before-phase) were collected for a period of 2 months to assess the quality of MCC decision making. Study teams selected the intervention strategies they wished to engage with. Post-intervention data (after-phase) were collected for 4 months. Implementation quality outcomes included reach, adherence/fidelity and adaptation. We also evaluated feasibility of data management. Decision making quality was evaluated on a per-case and per-round level using the MTB-MODe and MDT-OARS tools, respectively. RESULTS: There were a total of 149 cases and 23 MCCs observed in the before phase and 260 cases and 35 MCCs observed in the after phase. Teams implemented 3/5 strategies; adherence to selected strategies varied by MCC team. The per-round quality of MCCs improved by 11% (41.0 to 47.3, p = < 0.0001). The quality of per-case decision-making did not improve significantly (32.3 to 32.6, p = 0.781). CONCLUSION: While per round MCC decision making quality improved significantly, per-case decision-making quality did not. We posit that the limited improvements on decision making quality may be attributed to implementation quality gaps, including a lack of uptake of and adherence to theoretically-identified implementation strategies. Our findings highlight the importance of evaluating implementation quality and processes, iterative testing, and engagement of key gatekeepers in the implementation process.

Use of the theoretical domains framework and behaviour change wheel to develop a novel intervention to improve the quality of multidisciplinary cancer conference decision-making.

BACKGROUND: Multidisciplinary Cancer Conferences (MCCs) are prospective meetings involving cancer specialists to discuss treatment plans for patients with cancer. Despite reported gaps in MCC quality, there have been few efforts to improve its functioning. The purpose of this study was to use theoretically-rooted knowledge translation (KT) theories and frameworks to inform the development of a strategy to improve MCC decision-making quality. METHODS: A multi-phased approach was used to design an intervention titled the KT-MCC Strategy. First, key informant interviews framed using the Theoretical Domains Framework (TDF) were conducted with MCC participants to identify barriers and facilitators to optimal MCC decision-making. Second, identified TDF domains were mapped to corresponding strategies using the COM-B Behavior Change Wheel to develop the KT-MCC Strategy. Finally, focus groups with MCC participants were held to confirm acceptability of the proposed KT-MCC Strategy. RESULTS: Data saturation was reached at n = 21 interviews. Twenty-seven barrier themes and 13 facilitator themes were ascribed to 11 and 10 TDF domains, respectively. Differences in reported barriers by physician specialty were observed. The resulting KT-MCC Strategy included workshops, chair training, team training, standardized intake forms and a synoptic discussion checklist, and, audit and feedback. Focus groups (n = 3, participants 18) confirmed the acceptability of the identified interventions. CONCLUSION: Myriad factors were found to influence MCC decision making. We present a novel application of the TDF and COM-B to the context of MCCs. We comprehensively describe the barriers and facilitators that impact MCC decision making and propose strategies that may positively impact the quality of MCC decision making.

Using Deep Learning Algorithms to Grade Hydronephrosis Severity: Toward a Clinical Adjunct.

Grading hydronephrosis severity relies on subjective interpretation of renal ultrasound images. Deep learning is a data-driven algorithmic approach to classifying data, including images, presenting a promising option for grading hydronephrosis. The current study explored the potential of deep convolutional neural networks (CNN), a type of deep learning algorithm, to grade hydronephrosis ultrasound images according to the 5-point Society for Fetal Urology (SFU) classification system, and discusses its potential applications in developing decision and teaching aids for clinical practice. We developed a five-layer CNN to grade 2,420 sagittal hydronephrosis ultrasound images [191 SFU 0 (8%), 407 SFU I (17%), 666 SFU II (28%), 833 SFU III (34%), and 323 SFU IV (13%)], from 673 patients ranging from 0 to 116.29 months old (M age = 16.53, SD = 17.80). Five-way (all grades) and two-way classification problems [i.e., II vs. III, and low (0-II) vs. high (III-IV)] were explored. The CNN classified 94% (95% CI, 93-95%) of the images correctly or within one grade of the provided label in the five-way classification problem. Fifty-one percent of these images (95% CI, 49-53%) were correctly predicted, with an average weighted F1 score of 0.49 (95% CI, 0.47-0.51). The CNN achieved an average accuracy of 78% (95% CI, 75-82%) with an average weighted F1 of 0.78 (95% CI, 0.74-0.82) when classifying low vs. high grades, and an average accuracy of 71% (95% CI, 68-74%) with an average weighted F1 score of 0.71 (95% CI, 0.68-0.75) when discriminating between grades II vs. III. Our model performs well above chance level, and classifies almost all images either correctly or within one grade of the provided label. We have demonstrated the applicability of a CNN approach to hydronephrosis ultrasound image classification. Further investigation into a deep learning-based clinical adjunct for hydronephrosis is warranted.

Individualized pattern recognition for detecting mind wandering from EEG during live lectures.

NEURAL CORRELATES OF MIND WANDERING: The ability to detect mind wandering as it occurs is an important step towards improving our understanding of this phenomenon and studying its effects on learning and performance. Current detection methods typically rely on observable behaviour in laboratory settings, which do not capture the underlying neural processes and may not translate well into real-world settings. We address both of these issues by recording electroencephalography (EEG) simultaneously from 15 participants during live lectures on research in orthopedic surgery. We performed traditional group-level analysis and found neural correlates of mind wandering during live lectures that are similar to those found in some laboratory studies, including a decrease in occipitoparietal alpha power and frontal, temporal, and occipital beta power. However, individual-level analysis of these same data revealed that patterns of brain activity associated with mind wandering were more broadly distributed and highly individualized than revealed in the group-level analysis. MIND WANDERING DETECTION: To apply these findings to mind wandering detection, we used a data-driven method known as common spatial patterns to discover scalp topologies for each individual that reflects their differences in brain activity when mind wandering versus attending to lectures. This approach avoids reliance on known neural correlates primarily established through group-level statistics. Using this method for individual-level machine learning of mind wandering from EEG, we were able to achieve an average detection accuracy of 80-83%. CONCLUSIONS: Modelling mind wandering at the individual level may reveal important details about its neural correlates that are not reflected when using traditional observational and statistical methods. Using machine learning techniques for this purpose can provide new insight into the varieties of neural activity involved in mind wandering, while also enabling real-time detection of mind wandering in naturalistic settings.

Coaching by design: exploring a new approach to faculty development in a competency-based medical education curriculum.

As curricula move from a time-based system to a competency-based medical education system, faculty development will be required. Faculty will be asked to engage in the observation, assessment and feedback of tasks in the form of educational coaching. Faculty development in coaching is necessary, as the processes and tools for coaching learners toward competence are evolving with a novel assessment system. Here, we provide a scoping review of coaching in medical education. Techniques and content that could be included in the curricular design of faculty development programming for coaching (faculty as coach) are discussed based on current educational theory. A novel model of coaching for faculty (faculty as coachee) has been developed and is described by the authors. Its use is proposed for continuing professional development.

Enhancing Formative Feedback in Orthopaedic Training: Development and Implementation of a Competency-Based Assessment Framework.

OBJECTIVE: The purpose of this study was to develop, implement, and evaluate the effectiveness of an assessment framework aimed at improving formative feedback practices in a Canadian orthopaedic postgraduate training program. METHODS: Tool development began in 2014 and took place in 4 phases, each building upon the previous and informing the next. The reliability, validity, and educational impact of the tools were assessed on an ongoing basis, and changes were made accordingly. RESULTS: One hundred eighty-two tools were completed and analyzed during the study period. Quantitative results suggested moderate to excellent agreement between raters (intraclass correlation coefficient = 0.54-0.93), and an ability of the tools to discriminate between learners at different stages of training (p's < 0.05). Qualitative data suggested that the tools improved both the quality and quantity of formative feedback given by assessors and had begun to foster a culture change around assessment in the program. CONCLUSIONS: The tool development, implementation, and evaluation processes detailed in this article can serve as a model for other training programs to consider as they move towards adopting competency-based approaches and refining current assessment practices.

A Shift on the Horizon: A Systematic Review of Assessment Tools for Plastic Surgery Trainees.

BACKGROUND: As plastic surgery programs transition toward competency-based medical education curricula, it is important to critically assess current methods of evaluating trainee competence. The purpose of this systematic review was to identify and evaluate assessment tools for technical and nontechnical competencies in plastic surgery. METHODS: A systematic search using keywords related to competency-based medical education, assessment, and plastic surgery was conducted. Two independent reviewers extracted data pertaining to study characteristics, study design, and psychometric properties. Data pertaining to the establishment of competence and barriers to tool implementation were noted. RESULTS: Twenty-three studies were included in this review. Technical competencies were assessed in 16 studies. Nontechnical competencies were assessed in five studies. Two studies assessed both technical and nontechnical competence. Six tools were implemented in a simulated setting and 17 tools were implemented in a clinical setting. Thirteen studies (57 percent) did not report reliability scores and nine (39 percent) did not report validity scores. Two tools established clear definitions for competence. Common barriers to implementation included high demands on resources and time, uncertainty about simulation transferability, and assessor burnout. CONCLUSIONS: A number of tools exist to assess a range of plastic surgery skills, in both clinical and simulated settings. There is a need to determine the transferability of simulated assessments to clinical practice, as most available tools are simulation-based. Although additional psychometric testing of current assessment tools is required, particularly in the nontechnical domain, this review provides a base on which to build assessment frameworks that will support plastic surgery's transition to competency-based medical education.

Getting with the times: a narrative review of the literature on group decision making in virtual environments and implications for promotions committees.

INTRODUCTION: Concerns around the time and administrative burden of trainee promotion processes have been reported, making virtual meetings an attractive option for promotions committees in undergraduate and postgraduate medicine. However, whether such meetings can uphold the integrity of decision-making processes has yet to be explored. This narrative review aimed to summarize the literature on decision making in virtual teams, discuss ways to improve the effectiveness of virtual teams, and explore their implications for practice. METHODS: In August 2017, the Web of Science platform was searched with the terms 'decision making' AND 'virtual teams' for articles published within the last 20 years. The search yielded 336 articles, which was narrowed down to a final set of 188 articles. A subset of these, subjectively deemed to be of high-quality and relevant to the work of promotions committees, was included in this review. RESULTS: Virtual team functioning was explored with respect to team composition and development, idea generation and selection, group memory, and communication. While virtual teams were found to potentially offer a number of key benefits over face-to-face meetings including convenience and scheduling flexibility, inclusion of members at remote sites, and enhanced idea generation and external storage, these benefits must be carefully weighed against potential challenges involving planning and coordination, integration of perspectives, and relational conflict among members, all of which can potentially reduce decision-making quality. DISCUSSION: Avenues to address these issues and maximize the outcomes of virtual promotions meetings are offered in light of the evidence.

Surgical simulation training in orthopedics: current insights.

BACKGROUND: While the knowledge required of residents training in orthopedic surgery continues to increase, various factors, including reductions in work hours, have resulted in decreased clinical learning opportunities. Recent work suggests residents graduate from their training programs without sufficient exposure to key procedures. In response, simulation is increasingly being incorporated into training programs to supplement clinical learning. This paper reviews the literature to explore whether skills learned in simulation-based settings results in improved clinical performance in orthopedic surgery trainees. MATERIALS AND METHODS: A scoping review of the literature was conducted to identify papers discussing simulation training in orthopedic surgery. We focused on exploring whether skills learned in simulation transferred effectively to a clinical setting. Experimental studies, systematic reviews, and narrative reviews were included. RESULTS: A total of 15 studies were included, with 11 review papers and four experimental studies. The review articles reported little evidence regarding the transfer of skills from simulation to the clinical setting, strong evidence that simulator models discriminate among different levels of experience, varied outcome measures among studies, and a need to define competent performance in both simulated and clinical settings. Furthermore, while three out of the four experimental studies demonstrated transfer between the simulated and clinical environments, methodological study design issues were identified. CONCLUSION: Our review identifies weak evidence as to whether skills learned in simulation transfer effectively to clinical practice for orthopedic surgery trainees. Given the increased reliance on simulation, there is an immediate need for comprehensive studies that focus on skill transfer, which will allow simulation to be incorporated effectively into orthopedic surgery training programs.

A solution to gender inequity in surgery? Better caregiving policies.

SUMMARY: Attitudes toward women in surgery appear to be shifting in a positive direction. Why, then, do women still represent only 27% of surgeons in Canada? The answer may, at least in part, lie in the field's inability to adequately accommodate caregiving duties, which are still disproportionately "women's responsibilities" in our society. Although most Canadian academic centres now have paid maternity leave policies for trainees and faculty, these do not necessarily apply to surgeons working in the community, nor do they always reflect what occurs in practice. The perceived inability of the field to accommodate both personal and professional duties is often a significant deterrent to young women considering a career in surgery. In this commentary, we explore the need to address the "caregiver problem" as an important step toward achieving gender equity in surgery.

'It's not the form; it's the process': a phenomenological study on the use of creative professional development workshops to improve teamwork and communication skills.

INTRODUCTION: Past research has demonstrated the positive effects of visual and performing arts on health professionals' observational acuity and associated diagnostic skills, well-being and professional identity. However, to date, the use of arts for the development of non-technical skills, such as teamwork and communication, has not been studied thoroughly. METHODS: In partnership with a community print and media arts organisation, Centre[3], we used a phenomenological approach to explore front-line mental health and social service workers' experiences with a creative professional development workshop based on the visual and performing arts. Through preworkshop and postworkshop interviews with participants and postworkshop interviews with their managers, we sought to examine how participants' perceptions of the workshop compared with their preworkshop expectations, specific impacts of the workshop with respect to participants' teamwork and communication skills and changes in their perceptions regarding the use of the arts in professional development. RESULTS: Our workshops were successful in enhancing teamwork skills among participants and showed promise in the development of communication skills, though observable changes in workplace communication could not be confirmed. The workshop facilitated teamwork and collegiality between colleagues, creating a more enjoyable and accepting work environment. The workshops also helped participants identify the strengths and weaknesses of their communication skills, made them more comfortable with different communication styles and provided them with strategies to enhance their communication skills. CONCLUSIONS: Participation in the arts can be beneficial for the development of interpersonal skills such as teamwork and communication among health professionals.

Examining the barriers to meaningful assessment and feedback in medical training.

BACKGROUND: Recent reports from both accreditation bodies in North America highlight problems with current assessment practices in postgraduate medical training. Previous work has shown that educators might be reluctant to report poor performance or fail underperforming trainees. This study explores the barriers perceived by medical educators to providing more meaningful assessment and feedback to trainees. METHODS: Semistructured interviews were conducted with 22 physician educators. Interviews were audiotaped and transcribed verbatim. Three researchers analyzed the transcripts using a grounded theory approach. RESULTS: Participants expressed a reluctance to provide poor assessments or feedback to trainees. Fifty-five percent of the participants reported passing trainees who could have benefited from additional training. Our data revealed a number of barriers which may account for these findings. Implementing more frequent formative assessments could help educators more effectively evaluate trainees and provide feedback, although a shift in the culture of medicine may be required. CONCLUSION: It is imperative that the barriers to effective assessment and feedback identified in this study be addressed to improve postgraduate medical training and enhance patient care.