Medical competence as a multilayered construct.

BACKGROUND: The conceptualisation of medical competence is central to its use in competency-based medical education. Calls for 'fixed standards' with 'flexible pathways', recommended in recent reports, require competence to be well defined. Making competence explicit and measurable has, however, been difficult, in part due to a tension between the need for standardisation and the acknowledgment that medical professionals must also be valued as unique individuals. To address these conflicting demands, a multilayered conceptualisation of competence is proposed, with implications for the definition of standards and approaches to assessment. THE MODEL: Three layers are elaborated. This first is a core layer of canonical knowledge and skill, 'that, which every professional should possess', independent of the context of practice. The second layer is context-dependent knowledge, skill, and attitude, visible through practice in health care. The third layer of personalised competence includes personal skills, interests, habits and convictions, integrated with one's personality. This layer, discussed with reference to Vygotsky's concept of Perezhivanie, cognitive load theory, self-determination theory and Maslow's 'self-actualisation', may be regarded as the art of medicine. We propose that fully matured professional competence requires all three layers, but that the assessment of each layer is different. IMPLICATIONS: The assessment of canonical knowledge and skills (Layer 1) can be approached with classical psychometric conditions, that is, similar tests, circumstances and criteria for all. Context-dependent medical competence (Layer 2) must be assessed differently, because conditions of assessment across candidates cannot be standardised. Here, multiple sources of information must be merged and intersubjective expert agreement should ground decisions about progression and level of clinical autonomy of trainees. Competence as the art of medicine (Layer 3) cannot be standardised and should not be assessed with the purpose of permission to practice. The pursuit of personal excellence in this level, however, can be recognised and rewarded.

Contradictions and Opportunities: Reconciling Professional Identity Formation and Competency-Based Medical Education.

The widespread adoption of Competency-Based Medical Education (CBME) has resulted in a more explicit focus on learners' abilities to effectively demonstrate achievement of the competencies required for safe and unsupervised practice. While CBME implementation has yielded many benefits, by focusing explicitly on what learners are doing, curricula may be unintentionally overlooking who learners are becoming (i.e., the formation of their professional identities). Integrating professional identity formation (PIF) into curricula has the potential to positively influence professionalism, well-being, and inclusivity; however, issues related to the definition, assessment, and operationalization of PIF have made it difficult to embed this curricular imperative into CBME. This paper aims to outline a path towards the reconciliation of PIF and CBME to better support the development of physicians that are best suited to meet the needs of society. To begin to reconcile CBME and PIF, this paper defines three contradictions that must and can be resolved, namely: (1) CBME attends to behavioral outcomes whereas PIF attends to developmental processes; (2) CBME emphasizes standardization whereas PIF emphasizes individualization; (3) CBME organizes assessment around observed competence whereas the assessment of PIF is inherently more holistic. Subsequently, the authors identify curricular opportunities to address these contradictions, such as incorporating process-based outcomes into curricula, recognizing the individualized and contextualized nature of competence, and incorporating guided self-assessment into coaching and mentorship programs. In addition, the authors highlight future research directions related to each contradiction with the goal of reconciling 'doing' and 'being' in medical education.

Evaluating the feasibility and outcomes of a resident-led school-based pediatric clinic.

Objective: A resident-led school-based clinic to serve low-income populations was established in 2019 and served as a continuity clinic for pediatric residents at a single university. Our aim was to assess the feasibility, clinic outcomes, and resident experience of a resident-led school-based clinic (RLSBC), established in an elementary school that serves an underserved population. Methods: A retrospective chart review for the first 6 months (October 2019 to March 2020) of clinic operations was conducted. Feasibility metrics included the number of patients, visits and planned follow-ups; clinic outcomes included the number and type of presenting complaint, new diagnoses and interventions. Residents were also surveyed to assess their satisfaction and perceived learning in training at the school-based clinic. Results: Over the first 19 clinic days, 48 children were seen at the school-based clinic. Of the clinic users, 60% did not have a primary care physician, 46% received a new diagnosis, 46% received an intervention in the form of medication prescription, laboratory/imaging requisitions or referrals, and 96% received a treatment plan. Residents positively rated the experience of staffing the school-based clinic in all aspects, including learning environment, clinic and team environment, teaching obtained, practice management, and overall experience. Conclusion: A RLSBC is feasible and our outcomes suggest that such clinics may address health care needs of low-income families and children, while being a positively rated educational experience for pediatric residents.

Engaging Retired Physicians as Educators: Motivations and Experiences of Participants in a Novel Educational Program.

PURPOSE: Physician retirement has important impacts on medical learners as well as retiring physicians themselves. Retiring physicians take with them a wealth of knowledge, wisdom, and expertise and can feel a loss of identity, lack of fulfillment, and reduced social connectedness after leaving the institution. To address this, a novel educational program providing retired physicians with renewed educational roles was implemented in 2018 within a university-associated pediatric department. This study sought to explore the retired physicians' experiences in this new intergenerational program, including their motivations to reengage as educators after retirement. METHOD: The authors designed this study using qualitative description. Semistructured interviews were conducted in the Department of Pediatrics of McGill University in 2019 with retired physicians who participated in the educational program's inaugural year. Role theory and psychosocial development theory were used to design the interview guide and inform the thematic analysis. Iterative analysis of the interview transcripts was deductive and inductive. RESULTS: Of the 8 retired physicians who participated in the program's first cohort, 7 participated in this study. Analysis of the data yielded 4 main themes: a challenging shift to retirement, a desire for reengagement after retirement, role dissonance, and gaining by giving. The retired physicians were motivated to engage as educators. Although they experienced some discomfort in their new nonclinical roles, they described their experiences as fulfilling, with benefits such as intellectual stimulation, social connectedness, and a sense of purpose. CONCLUSIONS: Retired physicians' motivations to reengage academically and their experiences contributing to educational activities in this program highlight the importance of supporting physicians during the transition to retirement and establishing formal programs to engage retired physicians as educators.

Clinical Teachers' Perceptions of Their Role in Professional Identity Formation.

PURPOSE: A fundamental goal of medical education is supporting learners in forming a professional identity. While it is known that learners perceive clinical teachers to be critically important in this process, the latter's perspective is unknown. This study sought to understand how clinical teachers perceive their influence on the professional identity formation of learners. METHOD: In 2017, a research assistant conducted 16 semistructured interviews of clinical teachers from 8 specialties at McGill University. The research assistant audiorecorded and subsequently transcribed interviews for analysis. Following principles of qualitative description, the research team developed a coding scheme using both inductive codes (from the words of the participants) and deductive codes (based on the literature and the theory of communities of practice). Through a cross-case analysis, the team then identified salient themes. RESULTS: Participants struggled to describe their influence on learners' professional identity without first being prompted to focus on their own identity and its formation. Once prompted, clinical teachers reported viewing their personal and professional identities as integrated and believed that caring for patients was integral to forming their professional identity. They identified explicit role modeling, engaging in difficult conversations, and providing graded autonomy as ways in which they could influence the identity development of learners. However, they had difficulty discerning the magnitude of their influence. CONCLUSIONS: This study was the first to explore professional identity formation from the perspective of clinical teachers. The 2010 Carnegie Foundation report called for an increased focus on professional identity formation. Giving clinical teachers the space and guidance to reflect on this process, helping them make the implicit explicit, and supporting them in using their own experiences as learners to inform their teaching appear to be critical steps in achieving this goal.

Evaluating a novel resident role-modelling programme.

BACKGROUND: Role modelling is a fundamental method by which students learn from residents. To our knowledge, however, resident-as-teacher curricula have not explicitly addressed resident role modelling. The purpose of this project was to design, implement and evaluate an innovative programme to teach residents about role modelling. METHODS: The authors designed a resident role-modelling programme and incorporated it into the 2015 and 2016 McGill University resident-as-teacher curriculum. Influenced by experiential and social learning theories, the programme incorporated flipped-classroom and simulation approaches to teach residents to be aware and deliberate role models. Outcomes were assessed through a pre- and immediate post-programme questionnaire evaluating reaction and learning, a delayed post-programme questionnaire evaluating learning, and a retrospective pre-post questionnaire (1 month following the programme) evaluating self-reported behaviour changes. RESULTS: Thirty-three of 38 (87%) residents who participated in the programme completed the evaluation, with 25 residents (66%) completing all questionnaires. Participants rated the programme highly on a five-point Likert scale (where 1 = not helpful and 5 = very helpful; mean score, M = 4.57; standard deviation, SD = 0.50), and showed significant improvement in their perceptions of their importance as role models and their knowledge of deliberate role modelling. Residents also reported an increased use of deliberate role-modelling strategies 1 month after completing the programme. Resident-as-teacher curricula have not explicitly addressed resident role modelling DISCUSSION: The incorporation of resident role modelling into our resident-as-teacher curriculum positively influenced the participants' perceptions of their role-modelling abilities. This programme responds to a gap in resident training and has the potential to guide further programme development in this important and often overlooked area.

Describing medical student curiosity across a four year curriculum: An exploratory study.

BACKGROUND: Intellectual curiosity can be defined as a desire for knowledge that leads to exploratory behavior and consists of an inherent and stable trait (i.e. trait curiosity) and a variable context-dependent state (i.e. state curiosity). Although intellectual curiosity has been considered an important aspect of medical education and practice, its relationship to medical education has not been empirically investigated. The purpose of this exploratory study was to describe medical students' intellectual curiosity across a four-year undergraduate program. METHODS: We employed a cross-sectional design in which medical students, across a four-year undergraduate program at McGill University, completed the Melbourne Curiosity Inventory as a measure of their state and trait intellectual curiosity. A Mixed Models ANOVA was used to compare students across year of training. RESULTS: Four hundred and two out of 751 students completed the inventory (53.5%). Trait curiosity was significantly higher than state curiosity (M = 64.5, SD = 8.5 versus M = 58.5, SD = 11.6) overall, and within each year of training. CONCLUSIONS: This study is the first to describe state and trait intellectual curiosity in undergraduate medical education. Findings suggest that medical students' state curiosity may not be optimally supported and highlight avenues for further research.

Tiered curriculum in global child health: A novel CanMEDs-based multidisciplinary educational program.

Despite the importance of Global Child Health to the practice of 21st century paediatricians, formal comprehensive outcomes-based curricula in this area are lacking. This article describes the development and implementation of a novel, tiered, CanMEDs-based and multidisciplinary curriculum in Global Child Health that was based on a thorough review of the literature. In addition to detailing the steps and results of our literature review, we discuss the three tiers of our curriculum (General Track, Advanced Curriculum and Elective Track) as well as the evidence-informed curricular topics and learning outcomes associated with each tier. Moreover, we highlight the importance of a multidisciplinary approach to Global Child Health education and the potential for this work to help transition Global Child Health training to competency-based models of teaching and learning. This review may help hospitals and residency programs across Canada looking to develop more formal curricula in this often overlooked area.

Identifying Patients at High Risk of Loss of Response to Infliximab Maintenance Therapy in Paediatric Crohn's Disease.

BACKGROUND AND AIMS: Loss of response to infliximab resulting in discontinuation of therapy is a frequent problem encountered in paediatric Crohn's disease. Although identifying patients at risk of failure could have important implications for follow-up, literature in this area remains sparse. Our primary aim was to identify predictors of loss of response to infliximab among patients who were responders to induction. The secondary aim was to identify predictors of non-response to induction. METHODS: A retrospective cohort of patients with paediatric Crohn's disease treated with infliximab between 2000 and 2013 was followed until loss of response to infliximab or transfer to adult care. Predictors of response to induction therapy were studied by multivariate logistic regression. Time to treatment failure was analysed with a multivariate Cox model. RESULTS: Two-hundred and forty-eight patients were eligible for the study. Of these, 196 (79%) were responders to induction (57% clinical remission and 22% clinical response) and 52 (21%) were non-responders. Steroid resistance was the only variable independently associated with primary non-response (odds ratio [OR] 4.57, 95% confidence interval [CI] 1.67-12.50, p = 0.002). Thirty-one of the 196 responders discontinued infliximab due to loss of response after a mean of 1.6±1.3 years of treatment. Predictors of loss of response were level of response to induction (clinical response vs clinical remission, hazard ratio [HR] 3.74, 95% CI 1.80-7.80, p = 0.0004) and isolated colonic disease (HR 2.72, 95% CI 1.30-5.71, p = 0.008). CONCLUSIONS: Patients who fail to achieve clinical remission after induction and/or who have isolated colonic disease are at increased risk of loss of response to infliximab.

Resident Role Modeling: "It Just Happens".

PURPOSE: Role modeling by staff physicians is a significant component of the clinical teaching of students and residents. However, the importance of resident role modeling has only recently emerged, and residents' understanding of themselves as role models has yet to be explored. This study sought to understand residents' perceptions of themselves as role models, describe how residents learn about role modeling, and identify ways to improve resident role modeling. METHOD: Fourteen semistructured interviews were conducted with residents in internal medicine, general surgery, and pediatrics at the McGill University Faculty of Medicine between April and September 2013. Interviews were audio-recorded and subsequently transcribed for analysis; iterative analysis followed principles of qualitative description. RESULTS: Four primary themes were identified through data analysis: residents perceived role modeling as the demonstration of "good" behaviors in the clinical context; residents believed that learning from their role modeling "just happens" as long as learners are "watching"; residents did not equate role modeling with being a role model; and residents learned about role modeling from watching their positive and negative role models. CONCLUSIONS: While residents were aware that students and junior colleagues learned from their modeling, they were often not aware of role modeling as it was occurring; they also believed that learning from role modeling "just happens" and did not always see themselves as role models. Helping residents view effective role modeling as a deliberate process rather than something that "just happens" may improve clinical teaching across the continuum of medical education.

Residents as role models: impact on undergraduate trainees.

PURPOSE: Although researchers have investigated the value of physician role models, residents as role models have received less attention. The objectives of this study were to (1) investigate the importance of resident role models in the education and career choices of medical students, (2) examine the types of factors students judge to be most important in selecting resident role models, and (3) evaluate the specific attributes (within each factor type) that students perceive to be most important, comparing these attributes with those previously published on physician role models. METHOD: This was a cross-sectional, survey-based study, conducted in 2011, in which graduating medical students at McGill University completed a questionnaire on their perceptions of resident role models. The authors analyzed data using descriptive statistics and, for items with scalar responses, repeated measures analysis of variance. RESULTS: Of 165 possible student respondents, 151 (92%) completed the questionnaire. The findings suggest that (1) resident role models play an important role in both the education and career choice of medical students, (2) resident and attending staff role models are equally important to the education of medical students, although attending staff role models appear to be more important for students' career choices, and (3) the factors and specific attributes important in selecting resident role models align with those in previously published literature on physician role models. CONCLUSIONS: This study, suggesting that resident and attending physician role models are equally important to undergraduate education, highlights the importance of supporting residents in their status as role models.