Enabling Implementation of Competency Based Medical Education through an Outcomes-Focused Accreditation System.

Competency based medical education is being adopted around the world. Accreditation plays a vital role as an enabler in the adoption and implementation of competency based medical education, but little has been published about how the design of an accreditation system facilitates this transformation. The Canadian postgraduate medical education environment has recently transitioned to an outcomes-based accreditation system in parallel with the adoption of competency based medical education. Using the Canadian example, we characterize four features of an accreditation system that can facilitate the implementation of competency based medical education: theoretical underpinning, quality focus, accreditation standards, and accreditation processes. Alignment of the underlying educational theories within the accreditation system and educational paradigm drives change in a consistent and desired direction. An accreditation system that prioritizes quality improvement over quality assurance promotes educational system development and progressive change. Accreditation standards that achieve the difficult balance of being sufficiently detailed yet flexible foster a high fidelity of implementation without stifling innovation. Finally, accreditation processes that recognize the change process, encourage program development, and are not overly punitive all enable the implementation of competency based medical education. We also discuss the ways in which accreditation can simultaneously hinder the implementation of this approach. As education bodies adopt competency based medical education, particular attention should be paid to the role that accreditation plays in successful implementation.

Key considerations in planning and designing programmatic assessment in competency-based medical education.

Programmatic assessment as a concept is still novel for many in clinical education, and there may be a disconnect between the academics who publish about programmatic assessment and the front-line clinical educators who must put theory into practice. In this paper, we clearly define programmatic assessment and present high-level guidelines about its implementation in competency-based medical education (CBME) programs. The guidelines are informed by literature and by lessons learned from established programmatic assessment approaches. We articulate five steps to consider when implementing programmatic assessment in CBME contexts: articulate the purpose of the program of assessment, determine what must be assessed, choose tools fit for purpose, consider the stakes of assessments, and define processes for interpreting assessment data. In the process, we seek to offer a helpful guide or template for front-line clinical educators. We dispel some myths about programmatic assessment to help training programs as they look to design-or redesign-programs of assessment. In particular, we highlight the notion that programmatic assessment is not 'one size fits all'; rather, it is a system of assessment that results when shared common principles are considered and applied by individual programs as they plan and design their own bespoke model of programmatic assessment for CBME in their unique context.

Oncology education for family medicine residents: a national needs assessment survey.

BACKGROUND: This study aimed to determine the current state of oncology education in Canadian family medicine postgraduate medical education programs (FM PGME) and examine opinions regarding optimal oncology education in these programs. METHODS: A survey was designed to evaluate ideal and current oncology teaching, educational topics, objectives, and competencies in FM PGMEs. The survey was sent to Canadian family medicine (FM) residents and program directors (PDs). RESULTS: In total, 150 residents and 17 PDs affiliated with 16 of 17 Canadian medical schools completed the survey. The majority indicated their programs do not have a mandatory clinical rotation in oncology (79% residents, 88% PDs). Low rates of residents (7%) and PDs (13%) reported FM residents being adequately prepared for their role in caring for cancer patients (p = 0.03). Residents and PDs believed the most optimal method of teaching oncology is through clinical exposure (65% residents, 80% PDs). Residents and PDs agreed the most important topics to learn (rated ≥4.7 on 5-point Likert scale) were: performing pap smears, cancer screening/prevention, breaking bad news, and approach to patient with increased cancer risk. According to residents, other important topics such as appropriate cancer patient referrals, managing cancer complications and post-treatment surveillance were only taught at frequencies of 52, 40 and 36%, respectively. CONCLUSIONS: Current FM PGME oncology education is suboptimal, although the degree differs in the opinion of residents and PDs. This study identified topics and methods of education which could be focussed upon to improve FM oncology education.

Academic Half-Days: Facilitated Small Groups to Promote Interactive Learning.

BACKGROUND AND OBJECTIVES: Medical educators have expressed interest in using less didactic and more interactive formats for academic half-days (AHDs) in postgraduate residency training. We assessed the feasibility and effectiveness of implementing a practice-based small-group learning (PBSGL) process as one part of AHDs. METHODS: A mixed-methods approach was used. Over a two-year period, family medicine residents at the University of Calgary took part in PBSGL sessions during their AHDs, discussing clinical cases presented in evidence-based educational modules and reflecting on clinical experiences with the guidance of a trained peer facilitator. Data sources to explore experiences with the PBSGL process included an evaluation questionnaire, a practice reflection tool (PRT; documenting patient management plans) and individual interviews (n=19) with residents and faculty preceptors. RESULTS: Of 148 residents, 139 (93%) agreed to participate. Participants were divided into groups of 14-16 members to discuss 12 different module topics. Participants indicated that ongoing small-group interactions were helpful in meeting learning needs and provided opportunities to share and learn from experiences of others in a safe environment. Group facilitation by residents was successful. Level of resident participation and time to preread modules were factors contributing to successful small-group interactions. Modules were rated as effective learning tools, and sample cases were perceived as representing typical cases encountered in practice. Although participants intended to apply their learning to practice, follow through was hindered by lack of relevant clinical cases. CONCLUSIONS: Ongoing small-group learning facilitated by residents, coupled with evidence-based educational materials, was a feasible approach to AHDs.

Selection for family medicine residency training in Canada: How consistently are the same students ranked by different programs?

OBJECTIVE: To examine the consistency of the ranking of Canadian and US medical graduates who applied to Canadian family medicine (FM) residency programs between 2007 and 2013. DESIGN: Descriptive cross-sectional study. SETTING: Family medicine residency programs in Canada. PARTICIPANTS: All 17 Canadian medical schools allowed access to their anonymized program rank-order lists of students applying to FM residency programs submitted to the first iteration of the Canadian Resident Matching Service match from 2007 to 2013. MAIN OUTCOME MEASURES: The rank position of medical students who applied to more than 1 FM residency program on the rank-order lists submitted by the programs. Anonymized ranking data submitted to the Canadian Resident Matching Service from 2007 to 2013 by all 17 FM residency programs were used. Ranking data of eligible Canadian and US medical graduates were analyzed to assess the within-student and between-student variability in rank score. These covariance parameters were then used to calculate the intraclass correlation coefficient (ICC) for all programs. Program descriptions and selection criteria were also reviewed to identify sites with similar profiles for subset ICC analysis. RESULTS: Between 2007 and 2013, the consistency of ranking by all programs was fair at best (ICC = 0.34 to 0.39). The consistency of ranking by larger urban-based sites was weak to fair (ICC = 0.23 to 0.36), and the consistency of ranking by sites focusing on training for rural practice was weak to moderate (ICC = 0.16 to 0.55). CONCLUSION: In most cases, there is a low level of consistency of ranking of students applying for FM training in Canada. This raises concerns regarding fairness, particularly in relation to expectations around equity and distributive justice in selection processes.

Entrustment Decision Making in Clinical Training.

The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.

Moving into medical practice in a new community: the transition experience.

INTRODUCTION: Physicians undertake many transitions during the course of a medical career. The purpose of this study was to explore the experiences of physicians who moved to a new community. METHODS: A semistructured interview format was used to explore transitional experiences, including reasons for moving; the role of colleagues, learning, and organizational structures; how various mediating factors affected perceptions; and how the experience affected the physicians personally. We used qualitative methods in which data were collected, coded, and analyzed concurrently. RESULTS: 20 physicians from family medicine, internal medicine, and pediatrics described their experiences. Both the professional context and the geographic location affected physicians' perceptions of the move. Both internal and external mediating factors appeared to influence how physicians experienced and adjusted to the move. Physicians who joined functioning units appeared to have fewer problems. The physicians who had more difficulty were physicians who did not come to a specific job, often coming as the result of a spousal move; did not have a professional network in the city; had not sorted out licensure requirements; and were entering community (not institutional) practice. DISCUSSION: This study demonstrates the critical nature of institutional support structures to integrate the newcomer, collegial relationships within the workplace, and the importance of family and friends in mediating the adjustment period. Consideration should be given to structured mentorship or peer-buddy programs and longitudinal educational programs (eg, rounds) that may enable physicians to establish networks and gain practical local knowledge quickly.