Competence By Design: a transformational national model of time-variable competency-based postgraduate medical education.

Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide.

Asymptomatic surveillance testing for COVID-19 in health care professional students: lessons learned from a low prevalence setting.

The novel coronavirus disease of 2019 (COVID-19) pandemic has severely impacted the training of health care professional students because of concerns of potential asymptomatic transmission to colleagues and vulnerable patients. From May 27th, 2020, to June 23rd 2021; at a time when B.1.1.7 (alpha) and B.1.617.2 (delta) were the dominant circulating variants, PCR testing was conducted on 1,237 nasopharyngeal swabs collected from 454 asymptomatic health care professional students as they returned to their studies from across Canada to Kingston, ON, a low prevalence area during that period for COVID-19. Despite 46.7% of COVID-19 infections occurring in the 18-29 age group in Kingston, severe-acute-respiratory coronavirus-2 was not detected in any of the samples suggesting that negligible asymptomatic infection occurred in this group and that PCR testing in this setting may not be warranted as a screening tool.

Medical student wellness in Canada: time for a national curriculum framework.

There is substantial evidence showing that medical student wellness is a worsening problem in Canada. It is apparent that medical students' wellness deteriorates throughout their training. Medical schools and their governing bodies are responding by integrating wellness into competency frameworks and accreditation standards through a combination of system- and individual-level approaches. System-level strategies that consider how policies, medical culture, and the "hidden curriculum" impact student wellness, are essential for reducing burnout prevalence and achieving optimal wellness outcomes. Individual-level initiatives such as wellness programming are widespread and more commonly used. These are often didactic, placing the onus on the student without addressing the learning environment. Despite significant progress, there is little programming consistency across schools or training levels. There is no wellness curriculum framework for Canadian undergraduate medical education that aligns with residency competencies. Creating such a framework would help align individual- and system-level initiatives and smooth the transition from medical school to residency. The framework would organize goals within relevant wellness domains, allow for local adaptability, consider basic learner needs, and be learner-informed. Physicians whose wellness has been supported throughout their training will positively contribute to the quality of patient care, work environments, and in sustaining a healthy Canadian population.

Nous disposons d'un grand nombre de données concrètes démontrant que le bien-être des étudiants en médecine au Canada se détériore tout au long de leur cheminement universitaire et que le problème s'aggrave. Alliant les approches systémique et individuelle, les facultés de médecine et leurs directions réagissent en intégrant le bien-être dans les cadres de compétences et les normes d'agrément. Les stratégies systémiques, qui tiennent compte de l'impact des politiques, de la culture médicale et du «curriculum caché¼ sur le bien-être des étudiants, sont indispensables pour prévenir l'épuisement professionnel et pour obtenir des résultats optimaux en matière de bien-être. Les initiatives au niveau individuel, comme les programmes axés sur le bien-être, sont de plus en plus répandues. Ces programmes sont souvent didactiques et ils sollicitent l'étudiant sans tenir compte de l'environnement d'apprentissage. Bien que ces initiatives aient marqué des progrès importants, il y a peu d'uniformité entre les programmes des diverses facultés et entre les niveaux de formation. Il n'y a pas de cadre pédagogique pour les programmes d'études de premier cycle axés sur le bien-être au Canada s'alignant aux compétences visées dans les programmes de résidence. La création d'un tel cadre permettrait d'harmoniser les initiatives de niveau individuel et celles de niveau systémique et de faciliter la transition de la faculté de médecine vers la résidence. Il comporterait des objectifs organisés selon les domaines de bien-être pertinents, une souplesse permettant son adaptation aux divers milieux, il tiendrait compte des besoins fondamentaux des apprenants et il serait fondé sur une consultation de ces derniers. Les médecins dont le bien-être a été soutenu tout au long de leur formation contribueront de façon positive à la qualité des soins aux patients, à leur environnement de travail et au maintien d'une population canadienne en bonne santé.

A systems approach for institutional CBME adoption at Queen's University.

The Royal College of Physicians and Surgeons of Canada (RCPSC) has begun the transition to Competency by Design (CBD), a new curricular model for residency education that 'ensure[s] competence, but teaches for excellence'. By 2022, all Canadian specialty programs are anticipated to have completed the CBD cohort process which includes workshops facilitated by a Royal College Clinician Educator. Queen's University in Ontario, Canada, was granted approval by the RCPSC to embark upon an accelerated path to competency-based medical education (CBME) for all our postgraduate specialties. This accelerated path allowed us to take an institutional approach for CBME implementation and ensure that all specialities were part of a system-wide change. Our unique institution-wide approach to CBD is the first of its kind across Canada. From both a theoretical and practical perspective we undertook CBME using a systems approach that allowed us to build the foundations for CBME, implement the change, and plan for sustainability. This has created opportunities to bridge and connect the various programs involved in the implementation of CBME on Queen's campus. The systems approach was an essential part of our strategy to develop a community dedicated to ensuring a successful CBME implementation.

Using outcome harvesting: Assessing the efficacy of CBME implementation.

RATIONALE: In 2015, Queen's University embarked on an institution-wide transition to a competency-based medical education (CBME) curriculum for all 29 postgraduate medical education programmes. On 1 July 2017, this goal was accomplished. With this mass transition came the requirement to assess the efficacy of implementation through a programme evaluation process, which included the use of outcome harvesting (Wilson-Grau). Outcome harvesting identified the intended and unintended outcomes of CBME implementation, which helped us understand how the intervention was achieved and how the relationship between behaviours and stakeholders contributed to the successful transition. METHODS: A systematic approach to document analysis was used to categorize the eight identified areas of implementation: governance, scholarship, faculty development, resident leadership, curriculum, assessment, communications, and technology. Documents (N = 443) were organized per project area and then coded thematically. Documents were then categorized for attribution to outcomes using the outcome harvesting approach. Outcomes were validated via interrater reliability and substantiated by stakeholders to verify accuracy of formulation and plausibility of its influence on the outcome. RESULTS: The harvest produced 38 outcomes, either intended or unintended, that can be attributed to CBME implementation at Queen's University. CONCLUSION: Using outcome harvesting to assess the efficacy of CBME implementation produced a robust set of themes and resultant outcomes that can be categorized as requirements for success of implementation of any curricular innovation. Emergent themes included collaboration, community of practice, and stakeholder commitment. More unique observations noted through the harvest process included new policy development, creation of learner ownership, and an increase in the output of scholarly activity involving CBME.

Comparison of Personal Video Technology for Teaching and Assessment of Surgical Skills.

BACKGROUND: Improvements in personal technology have made video recording for teaching and assessment of surgical skills possible. OBJECTIVE: This study compared 5 personal video-recording devices based on their utility (image quality, hardware, mounting options, and accessibility) in recording open surgical procedures. METHODS: Open procedures in a simulated setting were recorded using smartphones and tablets (MOB), laptops (LAP), sports cameras such as GoPro (SC), single-lens reflex cameras (DSLR), and spy camera glasses (SPY). Utility was rated by consensus between 2 investigators trained in observation of technology using a 5-point Likert scale (1, poor, to 5, excellent). RESULTS: A total of 150 hours of muted video were reviewed with a minimum 1 hour for each device. Image quality was good (3.8) across all devices, although this was influenced by the device-mounting requirements (4.2) and its proximity to the area of interest. Device hardware (battery life and storage capacity) was problematic for long procedures (3.8). Availability of devices was high (4.2). CONCLUSIONS: Personal video-recording technology can be used for assessment and teaching of open surgical skills. DSLR and SC provide the best images. DSLR provides the best zoom capability from an offset position, while SC can be placed closer to the operative field without impairing sterility. Laptops provide best overall utility for long procedures due to video file size. All devices require stable recording platforms (eg, bench space, dedicated mounting accessories). Head harnesses (SC, SPY) provide opportunities for "point-of-view" recordings. MOB and LAP can be used for multiple concurrent recordings.

Delivering on the promise of competency based medical education - an institutional approach.

The Royal College of Physicians and Surgeons of Canada (RCPSC) adopted a plan to transform, over a seven-year horizon (2014-2021), residency education across all specialties to competency-based medical education (CBME) curriculum models. The RCPSC plan recommended implementing a more responsive and accountable training model with four discrete stages of training, explicit, specialty specific entrustable professional activities, with associated milestones, and a programmatic approach to assessment across residency education. Embracing this vision, the leadership at Queen's University (in Kingston, Ontario, Canada) applied for and was granted special permission by the RCPSC to embark on an accelerated institutional path. Over a three-year period, Queen's took CBME from concept to reality through the development and implementation of a comprehensive strategic plan. This perspective paper describes Queen's University's approach of creating a shared institutional vision, outlines the process of developing a centralized CBME executive team and twenty-nine CBME program teams, and summarizes proactive measures to ensure program readiness for launch. In so doing, Queen's created a community of support and CBME expertise that reinforces shared values including fostering co-production, cultivating responsive leadership, emphasizing diffusion of innovation, and adopting a systems-based approach to transformative change.

Comparison of faculty versus structured peer-feedback for acquisitions of basic and intermediate-level surgical skills.

PURPOSE: Video feedback and faculty feedback has been shown to improve surgical performance; however, consistent access to faculty is challenging. We studied the utility of structured peer-feedback (PF) compared to faculty-feedback (FF) during acquisition of basic and intermediate surgical skills. METHODOLOGY: Two randomized non-inferiority trials were conducted with 1st (n = 30) and 2nd year (n = 29) medical students learning skin-lesion excision and closure (S), and single-layer hand-sewn bowel anastomosis (B), respectively. Five attempts were performed. PF participants used an Objective Structured Assessment of Technical Skills tool to guide feedback. Blinded raters assessed video-recorded performance, time and Integrity of the completed task were also assessed. RESULTS: For both tasks performance by PF was comparable to FF (P = 0.111). Both groups improved significantly: performance (B:P < 0.0001, S:P = 0.035), time (B:P = 0.043, S:P < 0.0001) and integrity (B:P < 0.0001, S:P < 0.032). CONCLUSION: Structured peer-feedback is equivalent to faculty-feedback in the acquisition of basic and intermediate surgical skills, giving students freedom to practice independently.

Using graphic illustrations to uncover how a community of practice can influence the delivery of compassionate healthcare.

Our modern-day frenetic healthcare culture has progressed to a state where healthcare professionals tend to detach themselves from the emotions of their patients/clients, rather than embed compassion into their daily practice. The AMS Phoenix Project: A Call to Caring was implemented with the goal to instil and sustain empathy and compassion in environments where clinicians learn and work. The purpose of this study is to report on how an interprofessional community of practice (CoP) of healthcare educators can contribute to a cultural shift in promoting and delivering compassion in healthcare through health professionals education. Using an imaginative creative autoethnography that adopts a narrative design through graphic illustrations, data were collected from 25 members of the Phoenix@Queen's CoP during a 1-day retreat. Data collection included a graphic recorder who visually depicted all retreat dialogue, field notes that highlighted emergent themes and artefacts produced during the day. Audio recordings of the discussions were used as secondary sources of data. Using thematic analysis, three themes emerged: the call to caring is a long and winding road with many barriers and rewards; CoP members experienced personal growth in and through the community; and the Phoenix@Queen's CoP matters in terms of professional relationships, leadership and moving forward a shared agenda about practising compassionate healthcare. This study describes the development of a CoP that moves away from traditional committees and discussions to an experiential creation of connections and shared meaning by its members. By using autoethnography, and by demonstrating how graphic illustration can be an innovative and creative method for recording and interpreting group discussions, we have demonstrated the accelerated development of an authentic CoP. With a richer and more authentic community, the shared goals of healthcare professional educators are more likely to be achieved.

Using Contribution Analysis to Evaluate Competency-Based Medical Education Programs: It's All About Rigor in Thinking.

Competency-based medical education (CBME) aims to bring about the sequential acquisition of competencies required for practice. Although it is being adopted in centers of medical education around the globe, there is little evidence concerning whether, in comparison with traditional methods, CBME produces physicians who are better prepared for the practice environment and contributes to improved patient outcomes. Consequently, the authors, an international group of collaborators, wrote this article to provide guidance regarding the evaluation of CBME programs.CBME is a complex service intervention consisting of multiple activities that contribute to the achievement of a variety of outcomes over time. For this reason, it is difficult to apply traditional methods of program evaluation, which require conditions of control and predictability, to CBME. To address this challenge, the authors describe an approach that makes explicit the multiple potential linkages between program activities and outcomes. Referred to as contribution analysis (CA), this theory-based approach to program evaluation provides a systematic way to make credible causal claims under conditions of complexity. Although CA has yet to be applied to medical education, the authors describe how a six-step model and a postulated theory of change could be used to examine the link between CBME, physicians' preparation for practice, and patient care outcomes.The authors argue that adopting the methods of CA, particularly the rigor in thinking required to link program activities, outcomes, and theory, will serve to strengthen understanding of the impact of CBME over time.

Learning theory and its application to the use of social media in medical education.

BACKGROUND: There is rapidly increasing pressure to employ social media in medical education, but a review of the literature demonstrates that its value and role are uncertain. OBJECTIVE: To determine if medical educators have a conceptual framework that informs their use of social media and whether this framework can be mapped to learning theory. METHODS: Thirty-six participants engaged in an iterative, consensus building process that identified their conceptual framework and determined if it aligned with one or more learning theories. RESULTS: The results show that the use of social media by the participants could be traced to two dominant theories-Connectivism and Constructivism. They also suggest that many medical educators may not be fully informed of these theories. CONCLUSIONS: Medical educators' use of social media can be traced to learning theories, but these theories may not be explicitly utilised in instructional design. It is recommended that formal education (faculty development) around learning theory would further enhance the use of social media in medical education.

Fundamental components of a curriculum for residents in health advocacy.

PURPOSE: To develop components of a curriculum for teaching and evaluating Residents as health advocates. METHOD: Modeled on the Delphi technique, the first step involved a multidisciplinary panel of 10 Queen's University health care providers with expertize in education and patient advocacy. In the context of four Advocacy questions: What is it?, Who does it?, How to teach it?, and How to evaluate it?, they discussed a curriculum framework including graded education, scholarly activity, role modeling, and case examples. In the second step, 24 faculty experts addressed two goals: (1) to identify attributes discussed by the expert panel in step 1 and corresponding measurable behaviours and (2) to refine the curriculum framework proposed in step 1 with emphasis on content and evaluation. RESULTS: Six attributes of a health advocate were identified; knowledgeable, altruistic, honest, assertive, resourceful, and up-to date. Behaviours that reflect these attributes were identified as desirable or undesirable and means of teaching were matched to the attributes. For most residents, skills would be developed in a graded fashion, progressing from advocating for the individual to society as a whole. CONCLUSIONS: This study provides a general framework from which specialty-specific curriculums for training health advocates can be developed.

Faculty's and residents' perceptions of teaching and evaluating the role of health advocate: a study at one Canadian university.

PURPOSE: To examine the views of faculty and residents about teaching and evaluating health advocacy, one of the more difficult CanMEDS roles to integrate into postgraduate medical education. METHOD: In 2002, two focus groups of faculty and two of residents at Queen's University, Kingston, Ontario, Canada, were asked standardized questions to elicit their answers to what was a health care advocate as understood and reported by teachers and residents, and what were the reported barriers and enhancers to teaching and evaluating the role of residents as health care advocates. RESULTS: The study found that faculty and residents knew little about how to teach and evaluate the role of the health advocate. There was consensus between the two types of groups with congruity between residents and faculty about the key issues. The one exception to this was the disconnect between the faculty members' belief that advocacy was an aspect of their daily work and the residents' apparent lack of awareness of this. The majority of participants were not familiar with the Royal College's description of the role of health advocate and were very keen to receive further guidance on teaching tools and methods of evaluation. CONCLUSION: The authors' hypothesis was that little is known about how to teach and evaluate the role of the health advocate. The results confirmed this and identified important areas upon which to build an educational framework. The definition of the health advocate and the expectations require clarity and direction. Academic programs would benefit from clear objectives.