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Background: Direct observation is an invaluable tool for assessing clinical skills. However, it is unclear whether trainees are regularly observed on internal medicine clinical teaching units (CTUs). Methods: A web-based survey was distributed to medical students and residents completing rotations on inpatient internal medicine CTUs. Participants recorded the frequency of direct observation and observational feedback received over the past week. Results: Of the 189 survey respondents, 76% reported receiving direct observation at least once. On average, six skill-specific observations were reported by each learner, with an average of two different skills being observed. Bedside clinical decision-making and physical examination skills were observed most frequently. Feedback was least often provided after the direct observation of physical examination and communication skills.Conclusions: A quarter of trainees were not regularly observed at the internal medicine CTUs. The optimal frequency of direct observation requires further study. Résumé Contexte: L’observation directe est un outil précieux d’évaluation des compétences cliniques. On ne sait pas si les stagiaires sont observés régulièrement dans les unités d’enseignement clinique (UEC) de médecine interne. Méthodologie: Un sondage en ligne a été transmis à des étudiants en médecine et à des résidents qui font des stages dans des UEC de médecine interne en milieu hospitalier. Les participants ont consigné la fréquence des observations directes et des rétroactions d’observations reçues au cours de la semaine précédente. Résultats: Sur les 189 répondants au sondage, 76 % ont déclaré avoir reçu une observation directe au moins une fois. En moyenne, six observations sur une compétence particulière ont été déclarées par chaque apprenant, le nombre moyen decompétences différences qui ont été observées étant de deux. Les compétences relatives à la prise de décision clinique au chevet du patient et à l’examen physique ont fait le plus souvent l’objet d’une observation. Une rétroaction est survenue le moins souvent après l’observation directe de l’examen physique et de l’aptitude à communiquer. Conclusions: Le quart des stagiaires n’ont pas été observés régulièrement à l’UEC de médecine interne. La fréquence optimale de l’observation directe doit faire l’objet d’une étude approfondie.

The 2019 CSIM national meeting included a workshop focused on current topics related to medical education across Canada. The workshop topics included leadership in education, teaching point of care ultrasound, teaching clinical reasoning, and using competency based medical education to design a maintenance of competency program for practicing specialists. This article reflects the experience and discussions from the session, with the goal of stimulating national conversations and collaborations betweenCSIM members.

ObjectivesCaring for dying hospitalised patients is a healthcare priority. Our objective was to understand the learning needs of front-line nurses on the general internal medicine (GIM) hospital wards, and perceived barriers to, and facilitators of, optimal end-of-life care.MethodsWe developed an 85-item survey informed by the Theoretical Domains Framework and Capability–Opportunity–Motivation–Behaviour system. We included demographics and two main domains (knowledge and practice; delivering end-of-life care) with seven subsections. Nurses from four GIM wards and the nursing resource team completed this survey. We analysed and compared results overall, by Capability, Opportunity, and Motivation, and by survey domain. We considered items with median scores 5 years).ResultsOur response rate was 60.5% (144/238). 51% had been practising for >5 years; most respondents were female (93.1%). Nurses had similar scores on the knowledge (mean 76.0%; SD 11.6%) and delivering care (mean 74.5% (8.6%)) domains. Scores for items associated with Capability were higher than those associated with Opportunity (median (first, third quartiles) 78.6% (67.9%, 87.5%) vs 73.9% (66.0%, 81.8%); p=0.04). Nurses practising >5 years had significantly higher scores on all analyses. Barriers included engaging with families having strong emotional reactions, managing goals of care conflicts between patients and families, and staffing challenges on the ward. Additional requested resources included formal training, information binders and more staff. Opportunities for consideration include formalised on-the-job training, access to comprehensive information, including symptom management at the end of life, and debriefing sessions.ConclusionsFront-line nurses reported an interest in learning more about end-of-life care and identified important barriers that are feasible to address. These results will inform specific knowledge translation strategies to build capacity among bedside nurses to enhance end-of-life care practices for dying patients on GIM wards.

Background Infection control protocols, including visitor restrictions, implemented during the COVID-19 pandemic threatened the ability to provide compassionate, family-centered care to patients dying in the hospital. In response, clinicians used videoconferencing technology to facilitate conversations between patients and their families. Objectives To understand clinicians’ perspectives on using videoconferencing technology to adapt to pandemic policies when caring for dying patients. Methods A qualitative descriptive study was conducted with 45 clinicians who provided end-of-life care to patients in 3 acute care units at an academically affiliated urban hospital in Canada during the first wave of the pandemic (March 2020-July 2020). A 3-step approach to conventional content analysis was used to code interview transcripts and construct overarching themes. Results Clinicians used videoconferencing technology to try to bridge gaps in end-of-life care by facilitating connections with family. Many benefits ensued, but there were also some drawbacks. Despite the opportunity for connection offered by virtual visits, participants noted concerns about equitable access to videoconferencing technology and authenticity of technology-assisted interactions. Participants also offered recommendations for future use of videoconferencing technology both during and beyond the pandemic. Conclusions Clinician experiences can be used to inform policies and practices for using videoconferencing technology to provide high-quality end-of-life care in the future, including during public health crises.

Context Assessment for and of learning in workplace settings is at the heart of competency-based medical education. In postgraduate medical education (PGME), entrustable professional activities (EPAs) and entrustment scales are increasingly used to assess competence. However, the educational impacts of these assessment approaches remain unknown. Therefore, this study aimed to explore trainee perceptions regarding the impacts of EPAs and entrustment scales on feedback and learning processes in the clinical setting. Methods Four focus groups were conducted with postgraduate trainees in anaesthesia, emergency medicine, general internal medicine and nephrology at McMaster University in Hamilton, Ontario, Canada. Data collection and analysis were informed by principles of constructivist grounded theory. Results Entrustable professional activities representing well-defined tasks are perceived as potentially effective drivers for feedback and learning. Use of EPAs and entrustment scales, however, may augment existing tensions between developmental (for learning) and decision-making (of learning) assessment functions. Three key dilemmas seem to influence the impact of EPA-based assessment approaches on residents' learning: (a) standardisation of outcomes versus flexibility in assessment to align with individual learning experiences; (b) assessment tasks focusing on performance standards versus opportunities for learning, and (c) feedback focusing on numeric entrustment scores versus narrative and dialogue. Use of entrustment as an assessment outcome may impact trainees' motivation and feelings of self-efficacy, further enhancing tensions between learning and performance. Conclusions Entrustable professional activities and entrustment scales may support assessment for learning in PGME. However, their successful implementation requires the careful management of dilemmas that arise in EPA-based assessment in order to support competence development.

BackgroundPandemic-related restrictions are expected to continue to shape end-of-life care and impact the experiences of dying hospitalised patients and their families.ObjectiveTo understand families’ experiences of loss and bereavement during and after the death of their loved one amidst the SARS-CoV-2 (COVID-19) pandemic.DesignQualitative descriptive study.SettingThree acute care units in a Canadian tertiary care hospital.ParticipantsFamily members of 28 hospitalised patients who died from March–July 2020.Main outcome measuresQualitative semistructured interviews conducted 6–16 months after patient death inquired about family experiences before and beyond the death of their loved one and garnered suggestions to improve end-of-life care.ResultsPandemic restrictions had consequences for families of dying hospitalised patients. Most family members described an attitude of acquiescence, some framing their experience as a sacrifice made for the public good. Families appreciated how clinicians engendered trust in the name of social solidarity while trying to mitigate the negative impact of family separation. However, fears about the patient’s experience of isolation and changes to postmortem rituals also created despair and contributed to long-lasting grief.ConclusionProfound loss and enduring grief were described by family members whose final connections to their loved one were constrained by pandemic circumstances. Families observed solidarity among clinical staff and experienced a sense of unity with staff, which alleviated some distress. Their suggestions to improve end-of-life care given pandemic restrictions included frequent, flexible communication, exceptions for family presence when safe, and targeted efforts to connect patients whose isolation is intensified by functional impairment or limited technological access.Trial registration numberNCT04602520; Results.

Background Team-based learning (TBL) promotes problem solving and teamwork, and has been applied as an instructional method in undergraduate medical education with purported benefits. Although TBL curricula have been implemented for residents, no published systematic reviews or guidelines exist for the development and use of TBL in graduate medical education (GME). Objective To review TBL curricula in GME, identify gaps in the literature, and synthesize a framework to guide the development of TBL curricula at the GME level. Methods We searched PubMed, MEDLINE, and ERIC databases from 1990 to 2014 for relevant articles. References were reviewed to identify additional studies. The inclusion criteria were peer-reviewed publications in English that described TBL curriculum implementation in GME. Data were systematically abstracted and reviewed for consensus. Based on included publications, a 4-element framework—system, residents, significance, and scaffolding—was developed to serve as a step-wise guide to planning a TBL curriculum in GME. Results Nine publications describing 7 unique TBL curricula in residency met inclusion criteria. Outcomes included feasibility, satisfaction, clinical behavior, teamwork, and knowledge application. Conclusions TBL appears feasible in the GME environment, with learner reactions ranging from positive to neutral. Gaps in the literature occur within each of the 4 elements of the suggested framework, including: system, faculty preparation time and minimum length of effective TBL sessions; residents, impact of team heterogeneity and inconsistent attendance; significance, comparison to other instructional methods and outcomes measuring knowledge retention, knowledge application, and skill development; and scaffolding, factors that influence the completion of preparatory work.

Background: Choosing Wisely Canada is a campaign that fosters conversations between physicians and patients about high-value health care. However, little is known about physicians’ readiness to have these conversations. Our objective was to determine how ready practising internists were to embrace and openly address high-value care during conversations with patients or their families. Methods: Practising internists in hospitals affiliated with McMaster University, Hamilton, Ontario, were invited to complete an electronic survey with 3 clinical scenarios: each had 3 low-value interventions that had been requested by the patient or family member. For each request, participants chose 1 of 3 statements reflecting how they would respond: a low-value statement agreeing to provide the intervention, an implicit high-value statement declining to provide the intervention without mentioning value or an explicit high-value statement declining to provide the intervention with mention of value. Results: Forty-four of 62 eligible physicians (71.0% response rate) participated in the survey. High-value statements were selected in 91% of cases. The implicit high-value statement was chosen more often than the explicit high-value statement (65.7% v. 25.5% of all responses, respectively; χ2 range 4.46–56.23, p < 0.05). Interpretation: Physicians favoured high-value care but frequently chose not to explicitly address value in their statements. Physicians seemed ready to embrace high-value health care practice, although they were not ready to openly discuss it with patients and their families.

Objective Advance care planning (ACP) can result in end-of-life care that is more congruent with patients’ values and preferences. There is increasing interest in video decision aids to assist with ACP. The objective of this study was to evaluate the impact of video decision aids on patients’ preferences regarding life-sustaining treatments (primary outcome). Design Systematic review and meta-analysis of randomised controlled trials. Data sources MEDLINE, EMBASE, PsycInfo, CINAHL, AMED and CENTRAL, between 1980 and February 2014, and correspondence with authors. Eligibility criteria for selecting studies Randomised controlled trials of adult patients that compared a video decision aid to a non-video-based intervention to assist with choices about use of life-sustaining treatments and reported at least one ACP-related outcome. Data extraction Reviewers worked independently and in pairs to screen potentially eligible articles, and to extract data regarding risk of bias, population, intervention, comparator and outcomes. Reviewers assessed quality of evidence (confidence in effect estimates) for each outcome using the Grading of Recommendations Assessment, Development and Evaluation framework. Results 10 trials enrolling 2220 patients were included. Low-quality evidence suggests that patients who use a video decision aid are less likely to indicate a preference for cardiopulmonary resuscitation (pooled risk ratio, 0.50 (95% CI 0.27 to 0.95); I 2 =65%). Moderate-quality evidence suggests that video decision aids result in greater knowledge related to ACP (standardised mean difference, 0.58 (95% CI 0.38 to 0.77); I 2 =0%). No study reported on the congruence of end-of-life treatments with patients’ wishes. No study evaluated the effect of video decision aids when integrated into clinical care. Conclusions Video decision aids may improve some ACP-related outcomes. Before recommending their use in clinical practice, more evidence is needed to confirm these findings and to evaluate the impact of video decision aids when integrated into patient care.