Intrinsic or Invisible? An Audit of CanMEDS Roles in Entrustable Professional Activities

Systems-Based Practice in Graduate Medical Education: Evolving Toward an Ideal Future State

ABSTRACT

Systems-based practice (SBP) was first introduced as a core competency in graduate medical education (GME) in 2002 by the Accreditation Council for Graduate Medical Education as part of the Outcomes Project. While inclusion of SBP content in GME has become increasingly common, there have also been well-documented stumbling blocks, including perceptions that SBP has eroded the amount of curricular time available for more medically focused competencies, is not relevant for some practice contexts, and is not introduced early enough in training. As a result, SBP learning experiences often feel disconnected from medical trainees' practical reality. In this commentary, the authors provide guidance regarding potential changes that may facilitate the evolution of SBP toward an ideal future state where graduates bring a systems science mindset to all aspects of their work. Specific suggestions include the following: (1) expanding the SBP toolbox to reflect current-day health system needs, (2) evolve the teaching methodology, (3) broadening the scope of relevant SBP content areas, and (4) emphasizing SBP as an integrated responsibility for all health care team members. Levers to enact this transformation exist and must be used to influence change at the learner, faculty, program, and clinical learning environment levels.Physicians operate within an increasingly complex health care system that highlights the intersection of health care with complex social, environmental, and relational contexts. Consequently, the role of SBP in both physician work responsibilities and educational requirements continues to expand. To meet this growing demand, GME must adapt how it supports and trains the next generation of systems thinkers, ensuring they understand how levers in the health care system directly affect health outcomes for their patients, and integrate SBP into the foundation of GME curricula in an inclusive, holistic, and unrestrained way.

In EPAs we trust, is quality and safety a must? A cross-specialty analysis of entrustable professional activity guides

PURPOSE

The inclusion of quality improvement (QI) and patient safety (PS) into CanMEDS reflects an expectation that graduating physicians are competent in these areas upon training completion. To ensure that Canadian postgraduate specialty training achieves this, the translation of QI/PS competencies into training standards as part of the implementation of competency-based medical education requires special attention.

METHODS

We conducted a cross-specialty, multi-method analysis to examine how QI/PS was incorporated into the EPA Guides across 11 postgraduate specialties in Canada.

RESULTS

We identify cross-specialty variability in how QI/PS is incorporated, positioned, and emphasized in EPAs and milestones. QI/PS was primarily referenced alongside clinical activities rather than as a sole competency or discrete activity. Patterns were characterized in how QI/PS became incorporated into milestones through repetition and customization. QI/PS was also decoupled, conceptualized, and emphasized differently across specialties.

CONCLUSIONS

Variability in the inclusion of QI/PS in EPAs and milestones has important implications considering the visibility and influence of EPA Guides in practice. As specialties revisit and revise EPA Guides, there is a need to balance the standardization of foundational QI/PS concepts to foster shared understanding while simultaneously ensuring context-sensitive applications across specialties. Beyond QI/PS, this study illuminates the challenges and opportunities that lie in bridging theoretical frameworks with practical implementation in medical education, prompting broader consideration of how intrinsic roles and emergent areas are effectively incorporated into competency-based medical education.

Through a Tainted Lens: A Qualitatve Study of Medical Learners' Thinking About Patient 'Deservingness' of Health Advocacy

Introduction

While health advocacy is a key component of many competency frameworks, mounting evidence suggests that learners do not see it as core to their learning and future practice. When learners do advocate for their patients, they characterize this work as 'going above and beyond' for a select few patients. When they think about advocacy in this way, learners choose who deserves their efforts. For educators and policymakers to support learners in making these decisions thoughtfully and ethically, we must first understand how they are currently thinking about patient deservingness.

Methods

We conducted qualitative interviews with 29 undergraduate and postgraduate medical learners, across multiple sites and disciplines, to discuss their experiences of and decision-making about health advocacy. We then carried out a thematic analysis to understand how learners decided when and for whom to advocate. Stemming from initial inductive coding, we then developed a deductive coding framework, based in existing theory conceptualizing 'deservingness.'

Results

Learners saw their patients as deserving of advocacy if they believed that the patient: was not responsible for their condition, was more in need of support than others, had a positive attitude, was working to improve their health, and shared similarities to the learner. Learners noted the tensions inherent in, and discomfort with, their own thinking about patient deservingness.

Discussion

Learners' decisions about advocacy deservingness are rooted in their preconceptions about the patient. Explicit curriculum and conversations about advocacy decisions are needed to support learners in making advocacy decisions equitably.

What are the learning objectives in surgical training - a systematic literature review of the surgical competence framework

OBJECTIVE

To map the landscape of contemporary surgical education through a competence framework by conducting a systematic literature review on learning outcomes of surgical education and the instructional methods applied to attain the outcomes.

BACKGROUND

Surgical education has seen a paradigm shift towards competence-based training. However, a gap remains in the literature regarding the specific components of competency taught and the instructional methods employed to achieve these outcomes. This paper aims to bridge this gap by conducting a systematic review on the learning outcomes of surgical education within a competence framework and the instructional methods applied. The primary outcome measure was to elucidate the components of competency emphasized by modern surgical curricula. The secondary outcome measure was to discern the instructional methods proven effective in achieving these competencies.

METHODS

A search was conducted across PubMed, Medline, ProQuest Eric, and Cochrane databases, adhering to PRISMA guidelines, limited to 2017-2021. Keywords included terms related to surgical education and training. Inclusion criteria mandated original empirical studies that described learning outcomes and methods, and targeted both medical students and surgical residents.

RESULTS

Out of 42 studies involving 2097 participants, most concentrated on technical skills within competency-based training, with a lesser emphasis on non-technical competencies. The effect on clinical outcomes was infrequently explored.

CONCLUSION

The shift towards competency in surgical training is evident. However, further studies on its ramifications on clinical outcomes are needed. The transition from technical to clinical competence and the creation of validated assessments are crucial for establishing a foundation for lifelong surgical learning.

The CanMEDS Competency Framework in laboratory medicine: a phenomenographic study exploring how professional roles are applied outside the clinical environment

Background

The CanMEDS Competency Framework is an internationally recognized model used to outline the proficiencies of a physician. It has predominantly been studied in clinical environments but not all medical specialties take part in direct patient contact. In laboratory medicine, the role of the physician is to promote and enhance patient diagnostics by managing and overseeing the functions of a diagnostic laboratory.

Methods

This phenomenographic study explores the lived experiences of biochemistry, microbiology, and pathology residency program directors to better understand how they utilize the CanMEDS competencies. Eight laboratory medicine program directors from across Canada were individually interviewed using a semi-structured interview, and the data was analysed using inductive thematic analysis.

Results

The findings show that the current framework is disconnected from the unique context of laboratory medicine with some competencies appearing unrelatable using the current standardized definitions and expectations. Nevertheless, participants considered the framework to be an appropriate blueprint of the competencies necessary for their professional environment, but to make it accessible more autonomy is required to adapt the framework to their needs.

Conclusion

Newer renditions of the CanMEDS Competency Framework should better consider the realities of non-clinical disciplines.

Adult congenital heart disease training in Europe: current status, disparities and potential solutions

OBJECTIVES

This study aimed to determine the status of training of adult congenital heart disease (ACHD) cardiologists in Europe.

METHODS

A questionnaire was sent to ACHD cardiologists from 34 European countries.

RESULTS

Representatives from 31 of 34 countries (91%) responded. ACHD cardiology was recognised by the respective ministry of Health in two countries (7%) as a subspecialty. Two countries (7%) have formally recognised ACHD training programmes, 15 (48%) have informal (neither accredited nor certified) training and 14 (45%) have very limited or no programme. Twenty-five countries (81%) described training ACHD doctors 'on the job'. The median number of ACHD centres per country was 4 (range 0-28), median number of ACHD surgical centres was 3 (0-26) and the median number of ACHD training centres was 2 (range 0-28). An established exit examination in ACHD was conducted in only one country (3%) and formal certification provided by two countries (7%). ACHD cardiologist number versus gross domestic product Pearson correlation coefficient=0.789 (p<0.001).

CONCLUSION

Formal or accredited training in ACHD is rare among European countries. Many countries have very limited or no training and resort to 'train people on the job'. Few countries provide either an exit examination or certification. Efforts to harmonise training and establish standards in exit examination and certification may improve training and consequently promote the alignment of high-quality patient care.

Grappling with key questions about assessment of the Health Advocate role

Introduction

Although the CanMEDS framework sets the standard for Canadian training, health advocacy competence does not appear to factor heavily into high stakes assessment decisions. Without forces motivating uptake, there is little movement by educational programs to integrate robust advocacy teaching and assessment practices. However, by adopting CanMEDS, the Canadian medical education community endorses that advocacy is required for competent medical practice. It's time to back up that endorsement with meaningful action. Our purpose was to aid this work by answering the key questions that continue to challenge training for this intrinsic physician role.

Methods

We used a critical review methodology to both examine literature relevant to the complexities impeding robust advocacy assessment, and develop recommendations. Our review moved iteratively through five phases: focusing the question, searching the literature, appraising and selecting sources, and analyzing results.

Results

Improving advocacy training relies, in part, on the medical education community developing a shared vision of the Health Advocate (HA) role, designing, implementing, and integrating developmentally appropriate curricula, and considering ethical implications of assessing a role that may be risky to enact.

Conclusion

Changes to assessment could be a key driver of curricular change for the HA role, provided implementation timelines and resources are sufficient to make necessary changes meaningful. To truly be meaningful, however, advocacy first needs to be perceived as valuable. Our recommendations are intended as a roadmap for transforming advocacy from a theoretical and aspirational value into one viewed as having both practical relevance and consequential implications.