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.

Acute Dyspnea With an Infiltrative Tracheal Mass.

CASE PRESENTATION: A 48-year-old woman presented to the ED with a nonproductive cough, shortness of breath, and stridor. She was otherwise healthy and had never used tobacco. The patient was mildly tachycardic but otherwise hemodynamically stable, afebrile, and saturating well on room air. She did not display any signs of increased work of breathing at rest. Although auscultation of her thorax indicated good air entry bilaterally without any adventitious sounds, stridor was elicited with forced expiration.

Optimizing the delivery of genetic and advanced diagnostic testing in the province of Ontario: challenges and implications for laboratory technology assessment and management in decentralized healthcare systems.

AIMS: The Canadian province of Ontario provides full coverage for its residents (pop.14.8 M) for hospital-based diagnostic testing. Historical governance of the healthcare system and a legacy scheme of health technology assessment (HTA) and financing has led to a suboptimal approach of adopting advanced diagnostic technology (i.e. protein expression, cytogenetic, and molecular/genetic) for guiding therapeutic decisions. The aim of this research is to explore systemic barriers and provide guidance to improve patient and care provider experiences by reducing delays and inequity of access to testing, while benefitting laboratory innovators and maximizing system efficiency. MATERIALS AND METHODS: A mixed-methods approach including literature review, semi-structured interviews, and a multi-stakeholder forum involving patient representatives (n = 1), laboratory leaders (n = 6), physicians (n = 5), Ministry personnel (n = 4), administrators (n = 3), extra-provincial experts, and researchers (n = 7), as well as pharmaceutical (n = 5) and diagnostic companies (n = 2). The forum considered evidence of good practices in adoption, implementation, and financing laboratory services and identified barriers as well as feasible options for improving advanced diagnostic testing in Ontario. RESULTS: Overarching challenges identified included: barriers to define what is needed; need for a clear approach to adoption; and the need for more oversight and coordination. Recommendations to address these included a shift to an anticipatory system of test adoption, creating a fit-for-purpose system of health technology management that consolidates existing evaluation processes, and modernizing the governance and financing of testing so that it is managed at a care-delivery level. CONCLUSIONS: The proposals for change in Ontario highlight the role that HTA, governance, and financing of health technology play along the continuum of a health technology life cycle within a healthcare system where decision-making is highly decentralized. Resource availability and capacity were not a concern - instead, solutions require higher levels of coordination and system integration along with innovative approaches to HTA.

Histologic and Genotypic Characterization of Lung Cancer in the Inuit Population of the Eastern Canadian Arctic.

Inuit are the Indigenous Arctic peoples and residents of the Canadian territory of Nunavut who have the highest global rate of lung cancer. Given lung cancer's mortality, histological and genomic characterization was undertaken to better understand the disease biology. We retrospectively studied all Inuit cases from Nunavut's Qikiqtani (Baffin) region, referred to the Ottawa Hospital Cancer Center between 2001 and 2011. Demographics were compiled from medical records and tumor samples underwent pathologic/histologic confirmation. Tumors were analyzed by next generation sequencing (NGS) with a cancer hotspot mutation panel. Of 98 patients, the median age was 66 years and 61% were male. Tobacco use was reported in 87%, and 69% had a history of lung disease (tuberculosis or other). Histological types were: non-small cell lung carcinoma (NSCLC), 81%; small cell lung carcinoma, 16%. Squamous cell carcinoma (SCC) represented 65% of NSCLC. NGS on 55 samples demonstrated mutation rates similar to public lung cancer datasets. In SCC, the STK11 F354L mutation was observed at higher frequency than previously reported. This is the first study to characterize the histologic/genomic profiles of lung cancer in this population. A high incidence of SCC, and an elevated rate of STK11 mutations distinguishes this group from the North American population.

Challenges of implementing competency-based medical education postgraduate training programs: the issue of context / Desafíos de la implementación de programas de formación de posgrado en educación médica basada en competencias: la cuestión del contexto

Introduction: Competency-based medical education (CBME) is being adopted worldwide. The aim of this paper is to discuss the evolution of CBME and address some perceived challenges in CBME curriculum development and implementation in postgraduate (residency) medical education. Methods: This is an opinion paper based on lived experiences and personal beliefs. The authors have professional training in medical education and are actively involved in CBME research, curriculum development and implementation around the world. Results: The issue of local and system-wide context seems to be of particular importance to individuals, programs, institutions, governing bodies and other stakeholders involved in the development and implementation of CBME programs. CBME has evolved differently at different places, and there are concerns regarding the fidelity of implementation. Stakeholders have been dealing with challenging questions in their CBME journeys, which reflect the varied, complex and dynamic nature of health and education systems. Recently, scholars have established core components of any CBME program. Discussion and conclusions: CBME design should benefit from ground-up strategies that consider the local context. It is essential to approach implementation with a quality improvement lens and pay special attention to the fidelity and integrity of the core CBME components.

Introducción: la educación médica basada en competencias (CBME) se está adoptando en todo el mundo. El objetivo de este artículo es discutir la evolución de la CBME y abordar algunos desafíos percibidos en el desarrollo y la implementación de los estándares de CBME en la educación médica de posgrado (residencia). Métodos: este es un artículo de opinión basado en experiencias vividas y creencias personales. Los autores tienen formación profesional en educación médica y participan activamente en la investigación, el desarrollo y la implementación de programas de CBME en varios países. Resultados: la cuestión del contexto local y de todo el sistema parece ser de particular importancia para las personas, los programas, las instituciones, los órganos de gobierno y otras partes inte-resadas involucradas en el desarrollo y la implementación de los programas de CBME. La CBME ha evolucionado de manera diferente en diferentes lugares y existen preocupaciones con respecto a la fidelidad de la implementación. Las partes interesadas han estado lidiando con cuestiones difíciles en sus proyectos de CBME, que reflejan la naturaleza variada, compleja y dinámica de los sistemas de salud y educación. Recientemente, los académicos han establecido componentes centrales de cualquier programa CBME. Discusión y conclusiones: el diseño de la CBME debería beneficiarse de estrategias de base que consideren el contexto local. Sin embargo, es importante abordar la implementación con una lente de mejora de la calidad y prestar especial atención a la fidelidad e integridad de los componentes centrales de la CBME.

Aerogenous Metastasis and Spread Through the Air Spaces - Distinct Entities or Spectrum of the Same Process?

Clinicopathological and imaging studies indicate that metastatic spread of cancer cells through the airways may occur in primary lung cancer. The term aerogenous metastasis was been proposed years before the concept of spread through the airspaces (STAS) was introduced in the current World Health Organization classification. The pathogenesis of STAS has not been fully elucidated. The current definition of STAS is controversial and limited to early stage adenocarcinomas. In this article, existing knowledge on the pathogenesis, histology, imaging findings, and clinical and prognostic significance of these 2 entities is presented.

How to Design and Foster Thoracic Oncology Multidisciplinary Cancer Conferences.

In this chapter, the authors review and discuss the literature on multidisciplinary cancer conferences (MCCs, aka tumor boards), clarifying the terminology, showing the evolution of the field, and providing an evidence-based perspective on positive outcomes, best practices, factors influencing the quality of MCCs, evaluation tools to assess the quality of MCCs, and quality improvement interventions for MCCs. The authors then discuss some perspectives from their MCC and initiatives that they undertook to improve the work of their team and the care that they provide to patients in the area of thoracic oncology.

Recognition of Hematopoietic Stem Cell Transplantation and Cellular Therapy Expertise to Promote Care Accessibility: A Formally Credentialed Area of Focused Competence in Canada.

Hematopoietic stem cell transplantation (HSCT) and cellular therapy (CT) exploit the therapeutic potential of manipulated or unmanipulated hematopoietic cells to treat diseases. While initially dedicated to the treatment of hematologic malignancies and disorders, the use of these therapies in several diseases and cancers is currently under investigation. Indications are currently booming. In the midst of this expansion, both the American Society for Transplantation and Cellular Therapy (ASTCT) and the European Society for Blood and Marrow Transplantation (EBMT) have highlighted the global shortage of hematologists adequately trained in this field of high expertise. This shortage in transplant physicians and cellular therapists can significantly impact patients' access to cell-based therapy. To address this unmet need and attract aspiring hematologists to the field of cellular therapy, as well as to standardize training, anticipating this trend, a Canadian national task force aiming to develop a structured academic program in HSCT and CT was created. Workshops were organized to identify and establish the fundamentals of the practice in HSCT and CT. These workshops followed a rigorous process in developing the competency-based training program established by the Royal College. The program begins with the development of the main tasks associated with the practice of the discipline and the evidence that trainees must provide to demonstrate that they can perform these tasks independently (the competence portfolio). It continues with the development of training requirements that summarize the knowledge, skills, and aptitudes required to perform these tasks, followed by specific exposure during training (milestones) essential to demonstrate the acquisition of these skills. HSCT and CT together is now formally recognized as an Area of Focused Competence (AFC) by the Royal College of Physicians and Surgeons of Canada, a national organization that provides oversight of the medical education of specialists in Canada. AFCs are areas of specialty medicine that address a legitimate societal and patient population need previously unmet by the system of primary and subspecialty disciplines. The AFC designation for HSCT and CT provides a standardized curriculum, training experience, and accreditation process to attract young hematologists and promote expertise and quality care to meet the needs of both patients and society. A critical number of highly qualified hematologists will ensure continuing expansion of accessibility to HSCT and CT.

Teaching and assessing intra-operative consultations in competency-based medical education: development of a workplace-based assessment instrument.

Competency-based medical education (CBME) is being implemented worldwide. In CMBE, residency training is designed around competencies required for unsupervised practice and use entrustable professional activities (EPAs) as workplace "units of assessment". Well-designed workplace-based assessment (WBA) tools are required to document competence of trainees in authentic clinical environments. In this study, we developed a WBA instrument to assess residents' performance of intra-operative pathology consultations and conducted a validity investigation. The entrustment-aligned pathology assessment instrument for intra-operative consultations (EPA-IC) was developed through a national iterative consultation and used clinical supervisors to assess residents' performance at an anatomical pathology program. Psychometric analyses and focus groups were conducted to explore the sources of evidence using modern validity theory: content, response process, internal structure, relations to other variables, and consequences of assessment. The content was considered appropriate, the assessment was feasible and acceptable by residents and supervisors, and it had a positive educational impact by improving performance of intra-operative consultations and feedback to learners. The results had low reliability, which seemed to be related to assessment biases, and supervisors were reluctant to fully entrust trainees due to cultural issues. With CBME implementation, new workplace-based assessment tools are needed in pathology. In this study, we showcased the development of the first instrument for assessing resident's performance of a prototypical entrustable professional activity in pathology using modern education principles and validity theory.

Dyspnea, focal wheeze, and a slow growing endobronchial tumor.

We describe a case of an otherwise healthy woman who presented with nonspecific respiratory symptoms, but was found to have recurrent focal findings on chest radiograph. Her CT scan showed an endobronchial lesion with distal bronchiectasis which was ultimately diagnosed as a mucoepidermoid carcinoma. In this report we discuss the clinical, radiographic, bronchoscopic and pathologic findings of rarely seen endobronchial mucoepidermoid tumors.

Impact of a 1-day urodynamic course on knowledge, perceptions, and attitudes of urology residents.

AIMS: No evidence-informed educational curriculum is available for designing urodynamics (UDS) courses. We evaluated the learning outcomes of a short-lasting urodynamic course for urology residents. METHODS: Urology residents of postgraduate years 4 and 5 (n = 13 and n = 1316, respectively) attended a 1-day urodynamic course. Learning objectives included patient preparation, indication and technique, terminology, trace interpretation, and impact on patient management. Instructional methods consisted of short lectures (3 h) and case-based discussions (7.5 h). Learners' reactions, modifications of perceptions and attitudes, and acquisition of knowledge and skills were assessed by three written tests with a single group, pretest, posttest 1, and posttest 2 design. Tests were conducted precourse, 1 week after, and 4 months after the course. RESULTS: All participants felt more confident in several urodynamic competencies after the course, including patient preparation, urodynamic indication and technique, terminology, trace interpretation, and impact for patient management. These perceptions remained unchanged after 4 months. Most became stricter in the indication of UDS, including 20 (87.0%) at posttest 1 and 8 (66.7%) at posttest 2. The mean number of correct answers in the knowledge evaluation was 52.2% versus 61.4% versus 56.7%, respectively at pretest, posttest 1, and posttest 2; p = 0.535). All participants rated the course as very useful or useful in both posttest evaluations. CONCLUSIONS: Our study demonstrates that a 1-day urodynamic course can promote lasting improvements in self-reported perceptions, attitudes, and urodynamic-related competencies of urology residents. Further studies using evidence-informed educational principles are needed to determine the effect of specific educational interventions on urodynamic competencies in different contexts.

A severe pleural complication associated with granulomatosis with polyangiitis.

We describe the case of a previously healthy male patient who presented to a respiratory clinic with sinusitis, pulmonary cavities, and hemoptysis. Three weeks following a diagnosis of Granulomatosis with Polyangiitis (GPA) and initiation of immunosuppressive treatment, the patient suddenly developed a large pneumothorax that was complicated by empyema. In this report we discuss and highlight the rare pleural complications associated with GPA, and alert clinicians to monitor for these important complications even after disease-modifying treatment is initiated.

Perianal Pagetoid Intraepithelial Carcinoma.

Extramammary Paget disease (EMPD) involving the perianal region is rare and challenging to manage. Primary EMPD involves stand-alone noninvasive lesions within the epidermis, while secondary EMPD involves phenotypically similar lesions derived from separate underlying malignancies. Differentiating between primary and secondary EMPD is challenging when no underlying malignancies are detected during workup. Continued reporting of perianal EMPD cases is encouraged so that risk stratification can be improved and patients can be managed with an appropriate level of aggressiveness. Herein, we report the case of a 74-year-old woman who chose aggressive surgical management after being diagnosed with perianal pagetoid intraepithelial carcinoma from a suspected occult underlying primary colorectal tumor.

An important cause of non-resolving pneumonia.

We describe the case of a young patient with a history of non-resolving pneumonia. She was diagnosed with a limited form of Granulomatosis with Polyangiitis (GPA), by percutaneous core needle lung biopsy. In this report, we discuss the definition and clinical implications of limited GPA, treatment options, and highlight the importance of considering vasculitis in the differential diagnosis of non-resolving pneumonia.

The Gross Appearance of a NUT Midline Carcinoma.

The NUT midline carcinoma (NMC) is a recently described and highly aggressive tumor that usually involves the head and neck and anterior mediastinum. Most patients with NMC present with metastases and are often treated with neoadjuvant chemotherapy and/or radiation therapy. As a consequence, surgical specimens are often piecemeal excisions demonstrating treatment effect. In this report, we provide what is to the best of our knowledge the first complete gross description of NMC resected in toto and without prior treatment. The patient in this case underwent a pneumonectomy for a lung mass with curative intent. On gross examination, the tumor was found to be arising from the mediastinum with a smooth border, and demonstrated only minimal invasion of the surrounding structures. However, lymphovascular invasion was present throughout and there was extensive involvement of surrounding lymph nodes. The gross appearance of the tumor in this case reaffirms that NMC is an aggressive malignancy that usually metastasizes before it invades locally.

Aerogenous metastases: a potential game changer in the diagnosis and management of primary lung adenocarcinoma.

OBJECTIVE: The purposes of this article are to summarize the relevant literature on aerogenous metastasis, explain the putative pathogenetic mechanism of aerogenous spread, present the characteristic imaging and pathologic features, and review the importance of aerogenous spread to staging and clinical management. CONCLUSION: Cumulative evidence suggests that aerogenous spread may exist and is underrecognized. Imaging features are helpful in differentiating possible aerogenous spread of tumor from hematogenous and lymphatic metastases and from synchronous primary tumors. The putative occurrence of intrapulmonary aerogenous metastasis of lung cancer has staging, management, and prognostic implications.