User-centered and theory-based design of a professional training program on shared decision-making with older adults living with neurocognitive disorders: a mixed-methods study.

BACKGROUND: We know little about the best approaches to design training for healthcare professionals. We thus studied how user-centered and theory-based design contribute to the development of a distance learning program for professionals, to increase their shared decision-making (SDM) with older adults living with neurocognitive disorders and their caregivers. METHODS: In this mixed-methods study, healthcare professionals who worked in family medicine clinics and homecare services evaluated a training program in a user-centered approach with several iterative phases of quantitative and qualitative evaluation, each followed by modifications. The program comprised an e-learning activity and five evidence summaries. A subsample assessed the e-learning activity during semi-structured think-aloud sessions. A second subsample assessed the evidence summaries they received by email. All participants completed a theory-based questionnaire to assess their intention to adopt SDM. Descriptive statistical analyses and qualitative thematic analyses were integrated at each round to prioritize training improvements with regard to the determinants most likely to influence participants' intention. RESULTS: Of 106 participants, 98 completed their evaluations of either the e-learning activity or evidence summary (93%). The professions most represented were physicians (60%) and nurses (15%). Professionals valued the e-learning component to gain knowledge on the theory and practice of SDM, and the evidence summaries to apply the knowledge gained through the e-learning activity to diverse clinical contexts. The iterative design process allowed addressing most weaknesses reported. Participants' intentions to adopt SDM and to use the summaries were high at baseline and remained positive as the rounds progressed. Attitude and social influence significantly influenced participants' intention to use the evidence summaries (P < 0.0001). Despite strong intention and the tailoring of tools to users, certain factors external to the training program can still influence the effective use of these tools and the adoption of SDM in practice. CONCLUSIONS: A theory-based and user-centered design approach for continuing professional development interventions on SDM with older adults living with neurocognitive disorders and their caregivers appeared useful to identify the most important determinants of learners' intentions to use SDM in their practice, and validate our initial interpretations of learners' assessments during the subsequent evaluation round.

Psychometric validation of the Laval developmental benchmarks scale for family medicine.

BACKGROUND: With the implementation of competency-based education in family medicine, there is a need for summative end-of-rotation assessments that are criterion-referenced rather than normative. Laval University's family residency program therefore developed the Laval Developmental Benchmarks Scale for Family Medicine (DBS-FM), based on competency milestones. This psychometric validation study investigates its internal structure and its relation to another variable, two sources of validity evidence. METHODS: We used assessment data from a cohort of residents (n = 1432 assessments) and the Rasch Rating Scale Model to investigate its reliability, dimensionality, rating scale functioning, targeting of items to residents' competency levels, biases (differential item functioning), items hierarchy (adequacy of milestones ordering), and score responsiveness. Convergent validity was estimated by its correlation with the clinical rotation decision (pass, in difficulty/fail). RESULTS: The DBS-FM can be considered as a unidimensional scale with good reliability for non-extreme scores (.83). The correlation between expected and empirical items hierarchies was of .78, p < .0001.Year 2 residents achieved higher scores than year 1 residents. It was associated with the clinical rotation decision. CONCLUSION: Advancing its validation, this study found that the DBS-FM has a sound internal structure and demonstrates convergent validity.

Professional training on shared decision making with older adults living with neurocognitive disorders: a mixed-methods implementation study.

BACKGROUND: Shared decision making with older adults living with neurocognitive disorders is challenging for primary healthcare professionals. We studied the implementation of a professional training program featuring an e-learning activity on shared decision making and five Decision Boxes on the care of people with neurocognitive disorders, and measured the program's effects. METHODS: In this mixed-methods study, we recruited healthcare professionals in family medicine clinics and homecare settings in the Quebec City area (Canada). The professionals signed up for training as a continuing professional development activity and answered an online survey before and after training to assess their knowledge, and intention to adopt shared decision making. We recorded healthcare professionals' access to each training component, and conducted telephone interviews with a purposeful sample of extreme cases: half had completed training and the other half had not. We performed bivariate analyses with the survey data and a thematic qualitative analysis of the interviews, as per the theory of planned behaviour. RESULTS: Of the 47 participating healthcare professionals, 31 (66%) completed at least one training component. Several factors restricted participation, including lack of time, training fragmentation into several components, poor adaptation of training to specific professions, and technical/logistical barriers. Ease of access, ease of use, the usefulness of training content and the availability of training credits fostered participation. Training allowed Healthcare professionals to improve their knowledge about risk communication (p = 0.02), and their awareness of the options (P = 0.011). Professionals' intention to adopt shared decision making was high before training (mean ± SD = 5.88 ± 0.99, scale from 1 to 7, with 7 high) and remained high thereafter (5.94 ± 0.9). CONCLUSIONS: The results of this study will allow modifying the training program to improve participation rates and, ultimately, uptake of meaningful shared decision making with patients living with neurocognitive disorders.

Talking about treatment benefits, harms, and what matters to patients in radiation oncology: an observational study.

BACKGROUND: Shared decision making is associated with improved patient outcomes in radiation oncology. Our study aimed to capture how shared decision-making practices-namely, communicating potential harms and benefits and discussing what matters to patients-occur in usual care. METHODS: We invited a convenience sample of clinicians and patients in a radiation oncology clinic to participate in a mixed methods study. Prior to consultations, clinicians and patients completed self-administered questionnaires. We audio-recorded consultations and conducted qualitative content analysis. Patients completed a questionnaire immediately post-consultation about their recall and perceptions. RESULTS: 11 radiation oncologists, 4 residents, 14 nurses, and 40 patients (55% men; mean age 64, standard deviation or SD 9) participated. Patients had a variety of cancers; 30% had been referred for palliative radiotherapy. During consultations (mean length 45 min, SD 16), clinicians presented a median of 8 potential harms (interquartile range 6-11), using quantitative estimates 17% of the time. Patients recalled significantly fewer harms (median recall 2, interquartile range 0-3, t(38) = 9.3, p < .001). Better recall was associated with discussing potential harms with a nurse after seeing the physician (odds ratio 7.5, 95% confidence interval 1.3-67.0, p = .04.) Clinicians initiated 63% of discussions of harms and benefits while patients and families initiated 69% of discussions about values and preferences (Chi-squared(1) = 37.8, p < .001). 56% of patients reported their clinician asked what mattered to them. CONCLUSIONS: Radiation oncology clinics may wish to use interprofessional care and initiate more discussions about what matters to patients to heed Jain's (2014) reminder that, "a patient isn't a disease with a body attached but a life into which a disease has intruded."

Quebec College of Family Physicians' new formal mentorship program.

PROBLEM ADDRESSED: The stresses that arise during the first years of practice can discourage future physicians from choosing family medicine. Quebec is experiencing challenges in recruiting clinical family physicians to replace those nearing retirement. Mentorship is a promising approach that supports future family physicians. OBJECTIVE OF PROGRAM: To help family physicians at the beginning of their practice to adequately cope with the issues and challenges that come with professional integration and their personal and professional development. PROGRAM DESCRIPTION: A 12-month program that pairs mentors with mentees, on the mentee's initiative; it provides supports for mentors (such as a community of practice), and it comprises meeting formats that encourage the participation of mentees and mentors from different geographic regions across Quebec. CONCLUSION: Engaging and supporting mentees and mentors are essential to success, but might also present organizational challenges to sustaining formal mentorship programs for new family physicians in Quebec.

How often do both core competencies of shared decision making occur in family medicine teaching clinics?

OBJECTIVE: To assess how often risk communication and values clarification occur in routine family medicine practice and to explore factors associated with their occurrence. DESIGN: Qualitative and quantitative cross-sectional study. SETTING: Five university-affiliated family medicine teaching clinics across Quebec. PARTICIPANTS: Seventy-one health professionals (55% physicians, 35% residents, 10% nurses or dietitians) and 238 patients (76% women; age range 16 to 82 years old). MAIN OUTCOME MEASURES: The presence or absence of risk communication and values clarification during visits in which decisions were made was determined. Factors associated with the primary outcome (both competencies together) were identified. The OPTION5 (observing patient involvement in decision making) instrument was used to validate the dichotomous outcome. RESULTS: The presence of risk communication and values clarification during visits was associated with OPTION5 scores (area under the curve of 0.80, 95% CI 0.75 to 0.86, P < .001). Both core competencies of shared decision making occurred in 150 of 238 (63%) visits (95% CI 54% to 70%). Such an occurrence was more likely when the visit included discussion about beginning something new, treatment options, or postponing a decision, as well as when health professionals preferred a collaborative decision-making style and when the visit included more decisions or was longer. Alone, risk communication occurred in 203 of 238 (85%) visits (95% CI 82% to 96%) and values clarification in 162 of 238 (68%) visits (95% CI 61% to 75%). CONCLUSION: Health professionals in family medicine are making an effort to engage patients in shared decision making in routine daily practice, especially when there is time to do so. The greatest potential for improvement might lie in values clarification; that is, discussing what matters to patients and families.

Task Demands in OSCEs Influence Learning Strategies.

THEORY: Models on pre-assessment learning effects confirmed that task demands stand out among the factors assessors can modify in an assessment to influence learning. However, little is known about which tasks in objective structured clinical examinations (OSCEs) improve students' cognitive and metacognitive processes. Research is needed to support OSCE designs that benefit students' metacognitive strategies when they are studying, reinforcing a hypothesis-driven approach. With that intent, hypothesis-driven physical examination (HDPE) assessments ask students to elicit and interpret findings of the physical exam to reach a diagnosis ("Examine this patient with a painful shoulder to reach a diagnosis"). HYPOTHESES: When studying for HDPE, students will dedicate more time to hypothesis-driven discussions and practice than when studying for a part-task OSCE ("Perform the shoulder exam"). It is expected that the whole-task nature of HDPE will lead to a hypothesis-oriented use of the learning resources, a frequent use of adjustment strategies, and persistence with learning. METHOD: In a mixed-methods study, 40 medical students were randomly paired and filmed while studying together for two hypothetical OSCE stations. Each 25-min study period began with video cues asking to study for either a part-task OSCE or an HDPE. In a crossover design, sequences were randomized for OSCEs and contents (shoulder or spine). Time-on-task for discussions or practice were categorized as "hypothesis-driven" or "sequence of signs and maneuvers." Content analysis of focus group interviews summarized students' perception of learning resources, adjustment strategies, and persistence with learning. RESULTS: When studying for HDPE, students allocate significantly more time for hypothesis-driven discussions and practice. Students use resources contrasting diagnoses and report persistence with learning. When studying for part-task OSCEs, time-on-task is reversed, spent on rehearsing a sequence of signs and maneuvers. CONCLUSIONS: OSCEs with similar contents but different task demands lead to opposite learning strategies regarding how students manage their study time. Measuring pre-assessment effects from a metacognitive perspective provides empirical evidence to redesign assessments for learning.

Validation of the 5-item doctor-patient communication competency instrument for medical students (DPCC-MS) using two years of assessment data.

BACKGROUND: Medical students on clinical rotations have to be assessed on several competencies at the end of each clinical rotation, pointing to the need for short, reliable, and valid assessment instruments of each competency. Doctor patient communication is a central competency targeted by medical schools however, there are no published short (i.e. less than 10 items), reliable and valid instruments to assess doctor-patient communication competency. The Faculty of Medicine of Laval University recently developed a 5-item Doctor-Patient Communication Competency instrument for Medical Students (DPCC-MS), based on the Patient Centered Clinical Method conceptual framework, which provides a global summative end-of-rotation assessment of doctor-patient communication. We conducted a psychometric validation of this instrument and present validity evidence based on the response process, internal structure and relation to other variables using two years of assessment data. METHODS: We conducted the study in two phases. In phase 1, we drew on 4991 student DPCC-MS assessments (two years). We conducted descriptive statistics, a confirmatory factor analysis (CFA), and tested the correlation between the DPCC-MS and the Multiple Mini Interviews (MMI) scores. In phase 2, eleven clinical teachers assessed the performance of 35 medical students in an objective structured clinical examination station using the DPCC-MS, a 15-item instrument developed by Côté et al. (published in 2001), and a 2-item global assessment. We compared the DPCC-MS to the longer Côté et al. instrument based on internal consistency, coefficient of variation, convergent validity, and inter-rater reliability. RESULTS: Phase 1: Cronbach's alpha was acceptable (.75 and .83). Inter-item correlations were positive and the discrimination index was above .30 for all items. CFA supported a unidimensional structure. DPCC-MS and MMI scores were correlated. Phase 2: The DPCC-MS and the Côté et al. instrument had similar internal consistency and convergent validity, but the DPCC-MS had better inter-rater reliability (mean ICC = .61). CONCLUSIONS: The DPCC-MS provides an internally consistent and valid assessment of medical students' communication with patients.

Attitudes of pediatric intensive care unit physicians towards the use of cognitive aids: a qualitative study.

BACKGROUND: Cognitive aids are increasingly recommended in clinical practice, yet little is known about the attitudes of physicians towards these tools. METHODS: We employed a qualitative, descriptive design to explore physician attitudes towards cognitive aids in pediatric intensive care units (PICUs). Semi-structured interviews elicited the opinions of a convenience sample of practicing PICU physicians towards the use of cognitive aids. We analyzed interview data for thematic content to examine the three factors of intention to use cognitive aids as defined by the Theory of Planned Behavior (TPB), attitudes, social norms, and perceived control. RESULTS: Analysis of 14 interviews suggested that in the PICU setting, cognitive aids are widely used. Discovered themes related to their use touched on all three TPB factors of intention and included: aids are perceived to improve team communication; aids may improve patient safety; aids may hinder clinician judgment; physicians may resist implementation if it occurs prior to demonstration of benefit; effective adoption requires cognitive aids to be integrated into local workplace culture; and implementation should take physician concerns into account. CONCLUSIONS: Our sample of PICU physicians were open to cognitive aids in their practice, as long as such aids preserve the primacy of clinical judgment, focus on team communication, demonstrate effectiveness through preliminary testing, and are designed and implemented with the local culture and work environment in mind. Future knowledge translation efforts to implement cognitive aids would benefit from consideration of these issues.

Influences of OSCE design on students' diagnostic reasoning.

CONTEXT: Some characteristics of assessments exert a strong influence on how students study. Understanding these pre-assessment learning effects is of key importance to the designing of medical assessments that foster students' reasoning abilities. Perceptions of the task demands of an assessment significantly influence students' cognitive processes. However, why and how certain tasks positively 'drive' learning remain unknown. Medical tasks can be assessed as coherent meaningful whole tasks (e.g. examining a patient based on his complaint to find the diagnosis) or can be divided into simpler part tasks (e.g. demonstrating the physical examination of a pre-specified disease). Comparing the benefits of whole-task and part-task assessments in a randomised controlled experiment could guide the design of 'assessments for learning'. OBJECTIVES: The purpose of this study was to determine whether the knowledge that an objective structured clinical examination (OSCE) will contain whole tasks, as opposed to part tasks, increases the use of diagnostic reasoning by medical students when they study for this assessment. METHODS: In this randomised, controlled, mixed-methods experiment, 40 medical students were randomly paired and filmed while studying together for two imminent physical examination OSCE stations. Each 25-minute study period began with video cues and ended with a questionnaire on cognitive loads. Cues disclosed either a part-task OSCE station (examination of a healthy patient) or a whole-task OSCE station (hypothesis-driven physical examination [HDPE]). In a crossover design, sequences were randomised for both task and content (shoulder or spine). Two blinded and independent authors scored all 40 videos in distinct randomised orders, listening to participants studying freely. Mentioning a diagnosis in association with a sign was scored as a backward association, and the opposite was scored as a forward association; both revealed the use of diagnostic reasoning. Qualitative data were obtained through group interviews. RESULTS: Studying for whole-task OSCE stations resulted in a greater use of diagnostic reasoning. Qualitative data triangulate these findings and show the precedence of cues sourced from the 'student grapevine'. CONCLUSIONS: In comparison with 'traditional' part-task OSCEs, whole-task OSCEs like the HDPE increase students' use of diagnostic reasoning during study time.

Content and Rationale of Junior and Senior Preceptors Responding to Residents' Educational Needs Revisited.

THEORY: Feedback and debriefing, as portrayed in expertise development and self-assessment, play critical roles in providing residents with useful information to foster their progress. HYPOTHESES: Prior work has shown that clinical preceptors' use of conceptual frameworks (CFs; ways of thinking based on theories, best practices, or models) while giving feedback to residents was positively associated with a greater diversity of responses. Also, senior preceptors produced more responses, used more CFs, and asked more probing-challenging questions than junior preceptors. The purpose was to confirm the generalization of these initial findings with a broader and better defined sample of preceptors. METHOD: We conducted a mixed-method study with 20 junior and 20 senior preceptors in a controlled environment to analyze their responses and rationales to residents' educational needs as portrayed in 6 written vignettes. The preceptors were recruited from 3 primary care specialties preceptors (family medicine, internal medicine, pediatrics) of the 3 French-speaking faculties of medicine in Québec, Canada. RESULTS: The preceptors increased the 2012 list of response topics (96 to 126) and doubled the number of distinct CFs (16 to 32). The junior and senior preceptors expressed the same number and diversity of CFs. On average, senior preceptors asked more clarification questions and reflected more than juniors on the learning process that occurs during case discussions. Preceptor specialty and prior training in medical education did not influence the number and diversity of responses and CFs, except that preceptors with prior training generated more responses per vignette and were more reflective. Senior preceptors had a stronger positive relationship between the number of total and distinct CFs and the number of responses than the juniors. CONCLUSIONS: Although senior preceptors did not give more responses or use more CFs compared to the prior study, they continue to probe residents more and reflected more. The positive relationship between responses and CFs has important implications for faculty development and calls for more research to better understand the specific contribution of CFs to feedback.

Le nouveau programme formel de mentorat du Collège québécois des médecins de famille.

PROBLÈME À L'ÉTUDE: Les stress inhérents à l'entrée en pratique peuvent décourager les futurs médecins de choisir la médecine de famille. Le Québec fait face à des problèmes de recrutement de médecins de famille en clinique pour remplacer ceux qui s'acheminent vers la retraite. Le mentorat s'avère être un moyen prometteur de soutenir la relève en médecine de famille. OBJECTIF DU PROGRAMME: Aider les médecins de famille en début de pratique à composer de manière satisfaisante avec les enjeux et les défis inhérents à l'insertion professionnelle et à leur développement personnel et professionnel. DESCRIPTION DU PROGRAMME: D'une durée de 12 mois, il se caractérise par des dyades mentoré-mentor, à l'initiative des mentorés; des moyens de soutien aux mentors, dont une communauté de pratique; des modalités de rencontres favorisant la participation de mentorés et de mentors provenant de diverses régions géographiques du Québec. CONCLUSION: L'engagement et le soutien des mentorés et des mentors sont des facteurs essentiels de réussite, mais aussi des défis organisationnels pour la pérennité de programmes formels de mentorat auprès des nouveaux médecins de famille du Québec.

Collaboration between family physicians and nurse clinicians: opinions of graduates in family medicine.

OBJECTIVE: To determine whether graduating family physicians are exposed to collaboration between family physicians and nurse clinicians during their training, as well as their opinions about shared care between doctors and nurse clinicians in the delivery of patient care. DESIGN: Anonymous online survey. SETTING: Two French-Canadian university family medicine residency programs. PARTICIPANTS: The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec. MAIN OUTCOME MEASURES: The extent to which nurse clinicians in graduating family physicians' training milieu were involved in preventive and curative patient care activities, and graduates' opinions about nurse clinicians sharing care with physicians. RESULTS: Of 343 graduates, 186 (54.2%) participated in the survey. Although as residents in family medicine their exposure to shared care with nurse clinicians was somewhat limited, respondents indicated that they were generally quite open to the idea of sharing care with nurse clinicians. More than 70% of respondents agreed or strongly agreed that nurse clinicians could adjust, according to protocols of clinical guidelines, the treatment of patients with diabetes, hypertension, and asthma, as well as regulate medication for pain control in terminally ill patients. By contrast, respondents were less favourable to nurse clinicians adjusting the treatment of patients with depression. More than 80% of respondents agreed or strongly agreed that nurse clinicians could initiate treatment via a medical directive for routine hormonal contraception, acne, uncomplicated cystitis, and sexually transmitted infections. Respondents' opinions on nurse clinicians initiating treatment for pharyngitis and otitis were more divided. CONCLUSION: Graduating family physicians are quite open to collaborating with nurse clinicians. Although they have observed some collaboration between physicians and nurses, there are areas of shared clinical activities in which they would benefit from further exposure and training.

"They were very very nice but just not very good": The interplay between resident-supervisor relationships and assessment in the emergency setting.

Purpose: Clinical supervisors hesitate to report learner weaknesses, a widely documented phenomenon referred to as "failure to fail." They also struggle to discuss weaknesses with learners themselves. Their reluctance to report and discuss learner weaknesses threatens the validity of assessment-of-learning decisions and the effectiveness of assessment for learning. Personal and interpersonal factors have been found to act as barriers to reporting learners' difficulties, but the precise role of the resident-supervisor relationship remains underexplored, specifically in the emergency setting. This study aims to better understand if and how factors related to the resident-supervisor relationship are involved in assessment of and for learning in the emergency setting. Methods: We conducted a qualitative study, using semistructured interviews of 15 clinical supervisors in emergency medicine departments affiliated with our institution. Transcripts were independently coded by three members of the team using an iterative mixed deductive-inductive thematic analysis approach. The team then synthesized the coding and discussed analysis following guidelines for thematic analysis. Results: Participating emergency medicine supervisors valued resident-supervisor relationships built on collaboration and trust and believed that such relationships support learning. They described how these relationships influenced assessment of and for learning and how in turn assessment influenced the relationship. Almost all profiles of resident-supervisor relationships in our study could hinder the disclosing of resident weaknesses, through a variety of mechanisms. To protect residents and themselves from the discomfort of disclosing weaknesses and to avoid deteriorating the resident-supervisor relationship, many downplayed or even masked residents' difficulties. Supervisors who described themselves as able to provide negative assessment of and for learning often adopted a more distant or professional stance. Conclusions: This study contributes to a growing literature on failure to fail by confirming the critical impact that the resident-supervisor relationship has on the willingness and ability of emergency medicine supervisors to play their part as assessors.

Use and teaching of pneumatic otoscopy in a family medicine residency program.

OBJECTIVE: To determine to what extent FPs teach and use pneumatic otoscopy and to identify the chief influences on this behaviour. DESIGN: Mixed-methods descriptive study conducted between March and May 2011. SETTING: The family medicine residency program at Laval University in Quebec city, Que. PARTICIPANTS: Directors of the family medicine teaching units (FMTUs), teachers, and residents. METHODS: We used questionnaires to assess the availability of pneumatic otoscopy equipment in 12 FMTUs, current behaviour and behavioural intention among physicians (residents and teachers) to use or teach pneumatic otoscopy, and facilitators and barriers to these practices. We also conducted 2 focus groups to further explore the facilitators of and barriers to using pneumatic otoscopy. We used descriptive statistics for quantitative data, transcribed the qualitative material, and performed content analysis. MAIN FINDINGS: Eight of the 12 FMTUs reported having pneumatic otoscopy equipment. Four had it in all of their consulting rooms, and 2 formally taught it. Nine (4%) of 211 physicians reported regular use of pneumatic otoscopy. Mean (SD) intention to teach or use pneumatic otoscopy during the next year was low (2.4 [1.0] out of 5). Teachers identified improved diagnostic accuracy as the main facilitator both for use and for teaching, while residents identified recommendation by practice guidelines as the main facilitator for use. All physicians reported lack of availability of equipment as the main barrier to use. The main barrier to teaching pneumatic otoscopy reported by teachers was that they did not use it themselves. In focus groups, themes of consequences, capabilities, and socioprofessional influences were most dominant. Residents clearly identified role modeling by teachers as facilitating the use of pneumatic otoscopy. CONCLUSION: Pneumatic otoscopy is minimally used and taught in the family medicine residency program studied. Interventions to increase its use should target identified underlying beliefs and facilitators of and barriers to its use and teaching.

Collaboration between family physicians and community pharmacists: opinions of graduates in family medicine.

OBJECTIVE: To ascertain the opinions of graduating family physicians about collaboration between family physicians and community pharmacists. DESIGN: Anonymous online survey. SETTING: Two French-Canadian university family medicine residency programs. PARTICIPANTS: The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec. MAIN OUTCOME MEASURES: Content of written prescriptions; frequency of and reasons for consultations with community pharmacists; and graduates' perceptions of sharing professional responsibilities with community pharmacists. RESULTS: The response rate was 54.2%. Overall, graduates were open to collaborating actively with community pharmacists. For example, at least 60% of graduates reported that it was important to write on prescriptions about any changes to patients' medication and creatinine clearance. Most graduates responded positively to sharing responsibility for the adjustment of treatment of patients with certain chronic conditions (88.3% for anticoagulation, 64.7% for hypercholesterolemia, 61.2% for hypertension, and 60.6% for diabetes) and for the initiation of treatment of minor conditions according to a collective prescription (80.6% for traveler's diarrhea, 74.1% for juvenile acne, and 73.6% for allergic rhinitis). However, such interprofessional collaboration requires that each professional group continues to adapt to its roles and responsibilities. CONCLUSION: Family medicine graduates are open to actively collaborating with community pharmacists, but they have some reservations regarding sharing certain responsibilities. As collaborative practices are changing, graduates' opinions should be documented once they are actually practising.

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.

[Feedback Guide for direct observation of family medicine residents in Canada: a francophone tool]. / Développement et mise à l'essai du Guide de rétroaction francophone pour l'observation directe des résidents en médecine familiale au Canada.

Background: There is no CanMEDS-FM-based milestone tool to guide feedback during direct observation (DO). We have developed a guide to support documentation of feedback for direct observation (DO) in Canadian family medicine (FM) programs. Methods: The Guide was designed in three phases with the collaboration of five Canadian FM programs with at least a French-speaking teaching site: 1) literature review and needs assessment; 2) development of the DO Feedback Guide; 3) testing the Guide in a video simulation context with qualitative content analysis. Results: Phase 1 demonstrated the need for a narrative guide aimed at 1) specifying mutual expectations according to the resident's level of training and the clinical context, 2) providing the supervisor with tools and structure in his observations 3) to facilitate documentation of feedback. Phase 2 made it possible to develop the Guide, in paper and electronic formats, meeting the needs identified. In phase 3, 15 supervisors used the guide for three levels of residence. The Guide was adjusted following this testing to recall the phases of the clinical encounter that were often forgotten during feedback (before consultation, diagnosis and follow-up), and to suggest types of formulation to be favored (stimulating questions, questions of clarification, reflections). Conclusion: Based on evidence and a collaborative approach, this Guide will equip French-speaking Canadian supervisors and residents performing DO in family medicine.