Twelve tips for efficient procedural simulation.

Procedural simulation (PS) is increasingly being used worldwide in healthcare for training caregivers in psychomotor competencies. It has been demonstrated to improve learners' confidence and competence in technical procedures, with consequent positive impacts on patient outcomes and safety. Several frameworks can guide healthcare educators in using PS as an educational tool. However, no theory-informed practical framework exists to guide them in including PS in their training programs. We present 12 practical tips for efficient PS training that translates educational concepts from theory to practice, based on the existing literature. In doing this, we aim to help healthcare educators to adequately incorporate and use PS both for optimal learning and for transfer into professional practice.

How core competencies are taught during clinical supervision: participatory action research in family medicine.

OBJECTIVES: The development of professional competence is the main goal of residency training. Clinical supervision is the most commonly used teaching and learning method for the development of core competencies (CCs). The literature provides little information on how to encourage the learning of CCs through supervision. We undertook an exploratory study to describe if and how CCs were addressed during supervision in a family medicine residency programme. METHODS: We selected a participatory action research design to engage participants in exploring their precepting practices. Eleven volunteer faculty staff and six residents from a large family medicine residency programme took part in a 9-month process which included three focus group encounters alternating with data gathering during supervision. We used mostly qualitative methods for data collection and analysis, with thematic content analysis, triangulation of sources and of researchers, and member checking. RESULTS: Participants realised that they addressed all CCs listed as programme outcomes during clinical supervision, albeit implicitly and intuitively, and often unconsciously and superficially. We identified a series of factors that influenced the discussion of CCs: (i) CCs must be both known and valued; (ii) discussion of CCs occurs in a constant adaptation to numerous contextual factors, such as residents' characteristics; (iii) the teaching and learning of CCs is influenced by six challenges in the preceptor-resident interaction, such as residents' active engagement, and (iv) coherence with other curricular elements contributes to learning about CCs. Differences between residents' and preceptors' perspectives are discussed. CONCLUSIONS: This is the first descriptive study focusing on the teaching of CCs during clinical supervision, as experienced in a family medicine residency programme. Content and process issues were equally influential on the discussion of CCs. Our findings led to a representation of factors determining the teaching and learning of CCs in supervision, and suggest directions for research, for faculty development, and for interventions with learners.

Redesigning family medicine residency in Canada: the triple C curriculum.

BACKGROUND AND OBJECTIVES: Despite a record of excellence, Canadian family medicine residency programs must respond to the changing face of health care and the needs of the population. A working group was established by the College of Family Physicians of Canada to review the current curriculum and make recommendations for change. METHODS: Literature reviews of current evidence regarding strategies in postgraduate medical education were carried out, and recent developments in medical education internationally were studied. After recommendations for curriculum change were drafted, workshops, presentations, and peer consultations were conducted over a 4-year period to test ideas and obtain stakeholder feedback. RESULTS: The core recommendation of the working group is: Residency programs in family medicine are to establish a competency-based curriculum that is comprehensive, focused on continuity, and centered in family medicine--The Triple C Competency-based Curriculum. The working group developed a new framework for family medicine competency in Canada, CanMEDS-FM, to support the transition. CONCLUSIONS: The Triple C Competency-based Curriculum was developed to redesign Canadian family medicine residencies based on a solid rationale. Recommendations for curricular change, as well as the competency framework, CanMEDS-FM, have been accepted enthusiastically by stakeholders. Implementation and evaluation phases are underway.

Introduction to core competencies in residency: a description of an intensive, integrated, multispecialty teaching program.

Postgraduate residency programs must ensure that residents are properly trained in all core competencies. The CanMEDS framework of the Royal College of Physicians and Surgeons of Canada has established seven such competencies: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. The authors describe an integrated, one-month multispecialty rotation for first-year residents, Introduction to CanMEDS Core Competencies, at Laval University, Quebec, Canada. The goal of the rotation was to offer an in-depth and simultaneous training in each of the seven competencies. A pilot rotation was offered from February 9 to March 7, 2004 and involved 42 residents from seven programs and 30 faculty. It addressed 12 content areas related to the core competencies, through teaching formats promoting experiential and reflective learning. It involved three significant innovations: an intensive month-long format, during which residents were freed from most clinical duties; a multispecialty teaching and socialization strategy between peers and with faculty; and an integrated reflective approach, to ensure residents' understanding of the relevance and application of the core competencies in their own specialty. Although demanding to organize, the pilot rotation was well received. Residents were rapidly introduced to all competencies, and they developed an integrated perspective of them. An evaluation of impact is underway.

Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice.

OBJECTIVE: To describe primary health care professionals' views on barriers and facilitators for implementing the Ottawa Decision Support Framework (ODSF) in their practice. METHODS: Thirteen focus groups with 118 primary health care professionals were performed. A taxonomy of barriers and facilitators to implementing clinical practice guidelines was used to content-analyse the following sources: reports from each workshop, field notes from the principal investigator and written materials collected from the participants. RESULTS: Applicability of the ODSF to the practice population, process outcome expectation, asking patients about their preferred role in decision making, perception that the ODSF was modifiable, time issues, familiarity with the ODSF and its practicability were the most frequently identified both as barriers as well as facilitators. Forgetting about the ODSF, interpretation of evidence, challenge to autonomy and total lack of agreement with using the ODSF in general were identified only as barriers. Asking about values, health professional's outcome expectation, compatibility with the patient-centered approach or the evidence-based approach, ease of understanding and implementation, and ease of communicating the ODSF were identified only as facilitators. CONCLUSION: These results provide insight on the type of interventions that could be developed in order to implement the ODSF in academic primary care practice. PRACTICE IMPLICATIONS: Interventions to implement the ODSF in primary care practice will need to address a broad range of factors at the levels of the health professionals, the patients and the health care system.

Generalism versus subspecialization: changes necessary in medical education.

During the initial Partners Meeting of the Association of Faculties of Medicine of Canada (AFMC), the Canadian Association for Medical Education (CAME), the College of Family Physicians of Canada (CFPC), the Medical Council of Canada (MCC), and the Royal College of Physicians and Surgeons of Canada (RCPSC) in May 2005, a plenary discussion and debate focused on the tensions that exist between generalist and subspecialty education within both the undergraduate and postgraduate educational programs in Canadian medical schools. Key issues identified in the debate included medical student selection, generalist representation on medical school faculty and in learning experiences, and the need for a greater teaching role and respect for generalism to be developed.

Supporting patients facing difficult health care decisions: use of the Ottawa Decision Support Framework.

OBJECTIVE: To investigate family physicians' views on factors that make health care decisions difficult for patients, interventions family physicians use to support patients making decisions, and interventions proposed by the Ottawa Decision Support Framework (ODSF). DESIGN: Thirteen group discussions. SETTING: Five family practice units. PARTICIPANTS: One hundred twenty family physicians. INTERVENTIONS: The multifaceted implementation intervention consisted of feedback from participants, a reminder at point of care, and an interactive workshop. During the workshop, family physicians were asked about their views on 2 videos both showing the concluding phase of a simulated clinical encounter with a woman facing a decision about hormone therapy. One video showed usual care; the other showed use of the ODSF process and related tools. Content was analyzed using observations by non-participants, field notes, material collected from participants during workshops, evaluation forms completed at the end of workshops, and comments written on exit questionnaires from the implementation trial. MAIN OUTCOME MEASURES: Family physicians' views on the types of difficult decisions their patients face, the factors that make decisions difficult for patients, the interventions family physicians use to support patients' decisions, and the interventions proposed by the ODSF. RESULTS: The 2 most frequently cited factors making decisions difficult for patients were experiencing uncertainty and fears about adverse outcomes. Before being introduced to the ODSF, participants had used mostly information-related strategies to provide decision support. After learning about the ODSF, participants overwhelmingly identified assessing patients' values as a priority. At the end of the workshop, the 5 changes in practice participants most frequently intended to make were, in order of importance, to assess patients' values, to ask about patients' preferred role in decision making, to screen for decisional conflict, to assess support or undue pressure on patients, and to increase patients' involvement in decision making. CONCLUSION: The ODSF process and related tools have the potential to broaden family physicians' views on supporting patients facing difficult decisions.

Using standardized patients to measure professional performance of physicians.

OBJECTIVE: To determine the nature of inaccuracies likely to occur when standardized patients (SPs) are used to measure physician behaviour and to evaluate the potential impact of these inaccuracies on estimates of physician performance. DESIGN: Secondary analysis from a randomized controlled trial. SETTING: Family physicians' offices. STUDY PARTICIPANTS: Eighteen individuals, each portraying one of two patient scenarios, made a total of 179 visits to 92 family physicians who were participating in a separate randomized controlled trial to evaluate the impact of an educational workshop on implementation of preventive guidelines. MAIN OUTCOME MEASURES: Accuracy of SPs' portrayal of the assigned scenarios and accuracy of their coding of physician performance, determined on the basis of audiotapes of the visits and correlated with indicators of physicians' preventive practices. RESULTS: Accuracy of portrayal of the patient scenario was 84.8% for the male SPs and 93.5% for the female SPs. Inaccuracies in portrayal had no impact on physician performance scores. Accuracy of coding of physician performance was 90.5% for the female SPs (kappa = 0.66) and 90.1% for the male SPs (kappa = 0.68). Coding inaccuracies occurred most frequently for assessment of alcohol consumption and advice against smoking. CONCLUSION: SPs can provide valid information about physicians' professional performance. However, standardization of their activities must not be taken for granted. It may be more difficult to obtain standardized coding for counselling activities, an aspect of physician visits for which SPs are particularly appropriate.

Comparative trial of a short workshop designed to enhance appropriate use of screening tests by family physicians.

BACKGROUND: Educational interventions that support the implementation of complex clinical practice guidelines (CPGs) require substantial time commitments from participants. We conducted a comparative study to evaluate if a 90-minute workshop would increase compliance with the recommendations of the Canadian Task Force on Preventive Health Care as well as decrease the ordering of tests not the subject of specific recommendations. METHODS: Eighty-seven family physicians from Quebec participated in the study. Group assignment was initially randomized, but, owing to logistic problems, randomization was not maintained. After unannounced visits, 2 standardized patients coded the physicians' performance of 23 items recommended for inclusion in the periodic health examination (10 for men and 13 for women) and 8 items recommended for exclusion (4 for both men and women). The "exposed" physicians were visited within 4 to 6 months after the workshop. The "nonexposed" physicians were visited within 4 to 6 months after consent was obtained but before they attended the workshop. We used linear regression analysis to determine if exposure to the workshop resulted in improved performance. RESULTS: Exposure to the workshop was not associated with a difference in the adjusted mean score for items recommended for inclusion (12.07 for exposed physicians v. 12.35 for those not exposed; maximal and ideal score 23; r = -0.28; 95% confidence interval [CI] = -1.63 to 1.08). However, workshop exposure was associated with lower adjusted mean scores for items recommended for exclusion (1.55 v. 3.17; maximal score 8, ideal score 0; r = -1.63; 95% CI = -2.50 to -0.75) and for other tests (3.59 v. 6.53; r = -2.95; 95% CI = -5.10 to -0.79). INTERPRETATION: A short workshop can decrease the ordering of unnecessary screening tests by family physicians. Given its low cost and its potential for general application, such an intervention can support the implementation of prevention CPGs.

Participants' perception of impact of a workshop on their preventive practices.

A 90-minute interactive workshop, offered to small groups on request, was developed to help physicians include evidence-based preventive interventions in their practices. Between 25 September 1996 and 10 December 1997, 593 family physicians throughout the Province of Quebec (Canada) participated in one of the 40 workshops presented in all the regions of Quebec. Almost all participants (98%) completed the self-administered questionnaire. Their opinion of the achievement of three workshop objectives were evaluated using a seven-point Likert scale (-3 to +3)as their perception of the direct impact of the workshop on their practice. The workshop objectives were reached to a high degree: 2.1 (sd 0.90) for prescribing a proper check-up for adults; 1.83(sd 1.02) for explaining to the patient the reasons motivating his/her choice to include or exclude certain tests; 2.09 (sd 0.93)for using concrete and useful tool facilitating the integration of preventive measures in his/her professional practice. Female physicians and those under 40 perceived that the objectives were reached to a greater degree. Participants indicate their intention to modify their practice according to the clinical practice guidelines presented in the workshop.