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Reducing treatment burden is a priority for people with cystic fibrosis, whose health has benefited from using new modulators that substantially increase CFTR protein function. The SIMPLIFY study aimed to assess the effects of discontinuing nebulised hypertonic saline or dornase alfa in individuals using the CFTR modulator elexacaftor plus tezacaftor plus ivacaftor (ETI).The SIMPLIFY study included two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials at 80 participating clinics across the USA in the Cystic Fibrosis Therapeutics Development Network. We included individuals with cystic fibrosis aged 12-17 years with percent predicted FEVFrom Aug 25, 2020, to May 25, 2022, a total of 672 unique participants were screened for eligibility for one or both trials, resulting in 847 total random assignments across both trials with 594 unique participants. 370 participants were randomly assigned in the hypertonic saline trial and 477 in the dornase alfa trial. Participants across both trials had an average ppFEVIn individuals with cystic fibrosis on ETI with relatively well preserved pulmonary function, discontinuing daily hypertonic saline or dornase alfa for 6 weeks did not result in clinically meaningful differences in pulmonary function when compared with continuing treatment.

The COVID-19 pandemic has disrupted many societal institutions, including health care and education. Although the pandemic's impact was initially assumed to be temporary, there is growing conviction that medical education might change more permanently. The International Competency-based Medical Education (ICBME) collaborators, scholars devoted to improving physician training, deliberated how the pandemic raises questions about medical competence. We formulated 12 broad-reaching issues for discussion, grouped into micro-, meso-, and macro-level questions. At the individual micro level, we ask questions about adaptability, coping with uncertainty, and the value and limitations of clinical courage. At the institutional meso level, we question whether curricula could include more than core entrustable professional activities (EPAs) and focus on individualized, dynamic, and adaptable portfolios of EPAs that, at any moment, reflect current competence and preparedness for disasters. At the regulatory and societal macro level, should conditions for licensing be reconsidered? Should rules of liability be adapted to match the need for rapid redeployment? We do not propose a blueprint for the future of medical training but rather aim to provoke discussions needed to build a workforce that is competent to cope with future health care crises.

The growing international adoption of competency-based medical education (CBME) has created a desire for descriptions of innovative assessment approaches that generate appropriate and sufficient information to allow for informed, defensible decisions about learner progress. In this article, the authors provide an overview of the development and implementation of the approach to programmatic assessment in postgraduate family medicine training programs in Canada, called Continuous Reflective Assessment for Training (CRAFT). CRAFT is a principles-guided, high-level approach to work-place based assessment that was intentionally designed to be adaptable to local contexts, including size of program, resources available, and structural enablers and barriers. CRAFT has been implemented in all 17 Canadian family medicine residency programs, with each program taking advantage of the high-level nature of the CRAFT guidelines to create bespoke assessment processes and tools appropriate for their local contexts. Similarities and differences in CRAFT implementation between 5 different family medicine residency training programs, representing both English and French language programs from both Western and Eastern Canada, are described. Despite the intentional flexibility of the CRAFT guidelines, notable similarities in assessment processes and procedures across the 5 programs were seen. A meta-evaluation of findings from programs that have published evaluation information supports the value of CRAFT as an effective approach to programmatic assessment. While CRAFT is currently in place in family medicine residency programs in Canada, given its adaptability to different contexts as well as promising evaluation data, the CRAFT approach shows promise for application in other training environments.

Adaptive expertise has been promoted as an emerging model of expertise in health professions education in response to the inherent complexities of patient care; however, as the concept increasingly influences the structure of professional training and practice, it creates the potential for misunderstandings of the definition and implications of adaptive expertise. To foster a common understanding of the concept, we conducted a scoping review to explore how adaptive expertise has been discussed within health professions education literature. Five databases-MedLine, PubMed, ERIC, CINAHL, and PsycINFO-were searched using the exact term "adaptive expertise", producing 212 unique articles. Fifty-eight articles met inclusion criteria. In the included articles, authors discussed the conceptual implications of adaptive expertise for health professions education, strategies for training for adaptive expertise, and research findings aimed at supporting the development of adaptive expertise or utilizing adaptive expertise as a theoretical framework. The goal of this scoping review is to establish a resource for frontline educators tasked with fostering the development of adaptive expertise in learners through education initiatives. A common understanding of adaptive expertise is essential to ensuring effective implementation in training programs.

Ebstein anomaly comprises approximately 1% of all congenital heart diseases. It occurs when the tricuspid valve fails to properly delaminate from the right ventricle, resulting in a clinical spectrum of abnormal tricuspid valve morphology and right ventricular dysfunction. Due to the anatomy of the tricuspid valve and right ventricle, as well as associated right- and left-sided pathology, patients are at risk for both right and left ventricular failure and the associated symptoms of each. Ebstein patients are also at risk for atrial arrhythmias, due to the atrial enlargement intrinsic to the anatomy, as well as the presence of potential accessory pathways. Arrhythmias are generally poorly tolerated, particularly in the setting of ventricular dysfunction. Cyanosis may also be present in Ebstein patients, due to the common occurrence of atrial communications, which can exacerbate other symptoms of heart failure. Treatment of heart failure can be through pharmacologic and procedural interventions, depending on the underlying cause of heart failure. While early heart failure symptoms may be treated with medical management, most Ebstein patients will require surgery. Various surgical and catheter-based interventions targeting the tricuspid valve and the atrialized right ventricular tissue have been developed to help treat the underlying cause of the heart failure. The optimal timing of transcatheter and surgical intervention in the Ebstein patient to prevent or treat heart failure needs further study.

Background Medical assistance in dying (MAID) became legal across Canada when Bill C-14 was passed in 2016. Currently, little is known about the most effective strategies for providing MAID education, and the importance of integrating MAID into existing curricula. In this study, a set of learning objectives (LOs) was developed to inform a foundational MAID curriculum in Canadian Family Medicine (FM) residency training programs. Methods Mixed methods were used to develop LOs based on a published needs assessment from a large, four-site family medicine residency program in southeastern Ontario. Draft LOs were evaluated and revised by faculty and resident leaders using a modified Delphi process and a focus group. LOs were mapped to the existing family medicine residency curriculum, as well as the College of Family Physicians of Canada’s Priority Topics. Results Nine LOs were developed to provide a foundational education regarding MAID. While all LOs could be mapped to the Domains of Clinical Care within the departmental curriculum, they mapped inconsistently to departmental Entrustable Professional Activities and the Priority Topics. LOs focused on patient education and identification of patient goals were most readily mapped to existing curricular framework, while LOs with MAID-exclusive content revealed gaps in the current curriculum. Conclusions The developed LOs provide a guide to ensure family medicine residents obtain generalist-level knowledge to counsel their patients about MAID. These LOs can serve as a model for developing LOs for both family medicine and specialist residency programs in Canada and in countries where MAID is legal.

Training programs have the dual responsibility of providing excellent training for their learners and ensuring their graduates are competent practitioners. Despite everyone’s best efforts a small minority of learners will be unable to achieve competence and cannot graduate. Unfortunately, program decisions for training termination are often overturned, not because the academic decision was wrong, but because fair assessment processes were not implemented or followed. This series of three articles, intended for those setting residency program assessment policies and procedures, outlines recommendations, from establishing robust assessment foundations and the beginning of concerns (Part One), to established concerns and formal remediation (Part Two) to participating in formal appeals and after (Part Three). With these 14 recommendations on how to get a grip on fair and defensible processes for termination of training, career-impacting decisions that are both fair for the learner and defensible for programs are indeed possible. They are offered to minimize the chances of academic decisions being overturned, an outcome which wastes program resources, poses patient safety risks, and delays the resident finding a more appropriate career path. This article (Part Three in the series of three) will focus on the formal appeals and what to do after the appeal., Les programmes de formation ont la double responsabilité de fournir une excellente formation aux apprenants et de s’assurer qu’à l’issue de celle-ci les diplômés sont des praticiens compétents. Malgré tous les efforts déployés, une petite minorité d’apprenants ne parviendra pas à atteindre le niveau de compétence requis pour obtenir son diplôme. Malheureusement, la décision de la direction du programme de mettre fin à la formation d’un étudiant est souvent annulée, non pas parce qu’elle n’était pas académiquement fondée, mais parce qu’on a omis d’appliquer ou de suivre un processus d’évaluation juste. Cette série de trois articles, destinée aux responsables des politiques et procédures d’évaluation des programmes de résidence, présente des recommandations concernant l’établissement de bases d’évaluation solides et l’émergence de préoccupations quant à la progression d’un résident dans le programme (première partie), les préoccupations confirmées et la remédiation formelle (deuxième partie), et enfin le processus d’appel formel et ses suites (troisième partie). La mise en œuvre de ces 14 recommandations sur la définition de processus justes et légitimes pour mettre fin à la formation d’un apprenant devrait permettre de prendre des décisions aux répercussions importantes pour la carrière qui sont néanmoins à la fois justes envers la personne et justifiées du point de vue du programme. Elles sont proposées pour éviter la révision des décisions de nature académique, qui entraîne un gaspillage de ressources pour le programme, pose des risques pour la sécurité des patients et retarde la recherche d’un cheminement de carrière plus approprié pour le résident. Cet article (le troisième d’une série en trois parties) portera sur les appels formels et sur ce qu’il conviendrait de faire à la suite de l’appel.

This article explores the intertextual links between The Buribunks and two of Schmitt’s early texts, Dictatorship and Political Romanticism, to instance his satiric method and critique of d...

INTRODUCTION Simulation is an effective method for teaching acute care skills but has not been comprehensively evaluated with family medicine (FM) residents. We developed a comprehensive simulation-based approach for teaching acute care skills to FM residents and assessed it for effectiveness. METHOD We compared the effectiveness of our standard acute care simulation training [Acute Care Rounds (ACR)] to a more comprehensive simulation-based acute care program, Nightmares-Family Medicine (NM). We used a self-reported comfort scale as well as video-captured performance on an acute care Objective Structured Clinical Examination (OSCE). Seventy-seven of our FM residents in their postgraduate year 1 between July 2012 and June 2015 participated in the study. Wilcoxon matched pairs and one-tailed t tests analysis was used for analyzing the comfort scale, Whitney-Mann, and χ for the OSCE performance. RESULTS Nightmares-Family Medicine's initial 2-day session significantly improved the resident's self-assessment scores on all 20 items of the questionnaire (P < 0.05). Time-matched ACR improved 11 of 20 items (P < 0.05) level. Follow-up NM sessions improved 5 to 8 of 20 items (P < 0.05). Follow-up ACR sessions improved 1 to 5 of 20 items (P < 0.05). The means taken at the end of postgraduate year 1 year were higher for 13 of 20 items in the NM group (P < 0.05) as compared with ACR group. The NM group scored significantly higher on both the mean scores of OSCE individual categories (P < 0.01) and the Global Assessment Score (P < 0.05). Significantly less NM residents failed the OSCE (n = 1/30, 3.3% vs n = 8/37, 21.6%, P < 0.05). CONCLUSIONS "Nightmares-Family Medicine" course is very effective at teaching acute care skills to FM residents and more so than our previous curriculum.

Training programs have the dual responsibility of providing excellent training for their learners and ensuring their graduates are competent practitioners. Despite everyone’s best efforts a small minority of learners will be unable to achieve competence and cannot graduate. Unfortunately, program decisions for training termination are often overturned, not because the academic decision was wrong, but because fair assessment processes were not implemented or followed. This series of three articles, intended for those setting residency program assessment policies and procedures, outlines recommendations, from establishing robust assessment foundations and the beginning of concerns (Part One), to established concerns and formal remediation (Part Two) to participating in formal appeals and after (Part Three). With these 14 recommendations on how to get a grip on fair and defensible processes for termination of training, career-impacting decisions that are both fair for the learner and defensible for programs are indeed possible. They are offered to minimize the chances of academic decisions being overturned, an outcome which wastes program resources, poses patient safety risks, and delays the resident finding a more appropriate career path. This article (Part Three in the series of three) will focus on the formal appeals and what to do after the appeal.

Training programs have the dual responsibility of providing excellent training for their learners and ensuring their graduates are competent practitioners. Despite everyone’s best efforts a small minority of learners will be unable to achieve competence and cannot graduate. Unfortunately, program decisions for training termination are often overturned, not because the academic decision was wrong, but because fair assessment processes were not implemented or followed. This series of three articles, intended for those setting residency program assessment policies and procedures, outlines recommendations, from establishing robust assessment foundations and the beginning of concerns (Part One), to established concerns and formal remediation (Part Two) to participating in formal appeals and after (Part Three). With these 14 recommendations on how to get a grip on fair and defensible processes for termination of training, career-impacting decisions that are both fair for the learner and defensible for programs are indeed possible. They are offered to minimize the chances of academic decisions being overturned, an outcome which wastes program resources, poses patient safety risks, and delays the resident finding a more appropriate career path. This article (Part Two in the series of three) will focus on what to do when concerns become established, and a formal remediation or probation is necessary.

Training programs have the dual responsibility of providing excellent training for their learners and ensuring their graduates are competent practitioners. Despite everyone’s best efforts a small minority of learners will be unable to achieve competence and cannot graduate. Unfortunately, program decisions for training termination are often overturned, not because the academic decision was wrong, but because fair assessment processes were not implemented or followed. This series of three articles, intended for those setting residency program assessment policies and procedures, outlines recommendations, from establishing robust assessment foundations and the beginning of concerns (Part One), to established concerns and formal remediation (Part Two) to participating in formal appeals and after (Part Three). With these 14 recommendations on how to get a grip on fair and defensible processes for termination of training, career-impacting decisions that are both fair for the learner and defensible for programs are indeed possible. They are offered to minimize the chances of academic decisions being overturned, an outcome which wastes program resources, poses patient safety risks, and delays the resident finding a more appropriate career path. This article (part one in the series of three) will focus on the foundational aspects of residency training and the emergence of concerns.

PROBLEM Accurate self-assessment is a critical skill for residents to develop to become safe, adaptive clinicians upon graduation. Physicians need to be able to identify and fill in knowledge and skill gaps to deal with rapid expansion of medical knowledge and unpredicted novel emerging medical issues. Residency training to date has not consistently focused on building these overarching skills, nor have the burgeoning assessment data that competency-based medical education (CBME) affords been used beyond their initial intent to inform summative assessment decisions. Both are important missed opportunities. APPROACH The Queen's University family medicine program adopted CBME in 2010. In 2011 it added the capacity for residents to electronically self-assess their daily performance, with preceptors reviewing and modifying as needed before submitting. In 2018 it designed software to report discordance between residents' self-assessment and preceptors' assessment of performance. OUTCOMES From 2011-2019, 56,585 field notes were submitted, 11,429 by residents, with 28% of those (3,200/11,429) showing discordance between residents' and preceptors' performance assessments. When discordant, residents assessed their performance as less competent (undercalled) than their preceptor did 73% of the time (2,336/3,200 field notes). For the 864 field notes (27% of 3,200 discordant notes) where residents rated their performance higher than their preceptor did (overcalled, for 162/1,120 (14%) residents), 6 residents overcalled performance to a dangerous extent (2 or 3 levels of supervision higher than what their supervisors assessed them at) and 26 repeatedly (greater than 5 times) overcalled their level of performance by 1 supervisory level. NEXT STEPS Inaccurate self-assessment (both overcalling and undercalling performance) has negative consequences. Awareness is a first step in addressing this. Discrepancy reports will now be used during regular academic reviews with residents to discuss the nature, degree, and frequency of discrepancies, with the intent of fostering improved self-assessment of performance.

Background: Workplace-based assessment (WBA), foundational to competency-based medical education, relies on preceptors providing feedback to residents. Preceptors however get little timely, formative, specific, actionable feedback on the effectiveness of that feedback. Our study aimed to identify useful qualities of feedback for family medicine residents and to inform improving feedback-giving skills for preceptors in PGME training program.Methods: This study employed a two-phase exploratory design. Phase 1 collected qualitative data from preceptor feedback given to residents through Field Notes (FNs) and quantitative data from residents who provided feedback to preceptor about the quality of the feedback given. Phase 2 employed focus groups to explore ways in which residents are willing to provide preceptors with constructive feedback about the quality of the feedback they receive. Descriptive statistics and a thematic approach were used for data analysis.Findings: We collected 22 FNs identified by residents as being impactful to their learning; analysis of these FNs resulted in five themes. Functionality was then added to the electronic FNs allowing residents to indicate impactful feedback with a “Thumbs Up” icon. Over one year, 895 out of 8,496 FNs (11%) had a “Thumbs up” added, divided into reasons of: confirmation of learning (28.6%), practice improvement (21.2%), new learning (18.8%), motivation (17.7%), and evoking reflection (13.7%). Two focus groups (12 residents, convenience sampling) explored residents’ perception of constructive feedback and willingness to also provide constructive feedback to preceptors.Conclusion: Adding constructive feedback to existing positive feedback choices will provide preceptors with holistic information about the impact of their feedback on learners, which, in turn, should allow them to provide more effective feedback to learners. However, power differential, relationship impact, and institutional support were concerns for residents that would need to be addressed for this to be optimally operationalized., Contexte : L’évaluation en milieu de travail (EMT), qui est à la base de la formation médicale fondée sur les compétences, repose sur la rétroaction donnée par les superviseurs aux résidents. En revanche, il est rare que les superviseurs reçoivent à leur tour, et en temps utile, une rétroaction formative, précise et pratique sur l’efficacité des commentaires qu’ils ont offerts. L’objectif de notre étude était de déceler les caractéristiques qu’un tel retour doit avoir pour être utile aux résidents en médecine familiale afin de guider l’amélioration des compétences en rétroaction des superviseurs de programmes d’éducation médicale postdoctorale.Méthodes : Nous avons utilisé un devis exploratoire en deux phases. Lors de la première phase, nous avons recueilli les données qualitatives à partir des commentaires fournis par les précepteurs aux résidents par le biais de feuilles de route (FR) et les données quantitatives de rétroactiondes résidents sur la qualité de la rétroaction qui leur a été offerte par les superviseurs. Dans la phase 2, des groupes de discussion ont été constitués pour explorer les moyens par lesquels les résidents sont prêts à fournir aux superviseurs une rétroaction constructive sur la qualité de la rétroaction qu’ils reçoivent. L’analyse des données a été faite à l’aide de statistiques descriptives et d’une approche thématique.Résultats : Les auteurs ont recueilli 22 feuilles de route (FR) qui, d’après les résidents, ont eu un effet sur leur apprentissage. L’analyse des FR a permis de relever cinq thèmes. Une fonctionnalité a par la suite été ajoutée aux FR électroniques, permettant aux résidents d’indiquer qu’une rétroaction a été efficace à l’aide d’un pictogramme « Pouce levé ». En un an, 895 des 8496 FR (11 %) ont reçu un « Pouce levé » et les raisons qui l’expliquent sont réparties de la manière suivante : la rétroaction confirmait au résident ses acquis (28,6 %), elle l’aidait à améliorer sa pratique (21,2 %), elle lui apprenait quelque chose de nouveau (18,8 %), elle stimulait sa motivation (17,7 %) ou encore sa réflexion (13,7 %). Deux groupes de discussion (12 résidents, échantillon de convenance) ont exploré ce que les résidents perçoivent comme étant une rétroaction constructive, et s’ils sont prêts à fournir à leur tour un commentaire constructif aux superviseurs.Conclusion : Le fait d’ajouter des commentaires constructifs aux commentaires positifs renseignerait les superviseurs de manière plus complète sur l’effet qu’a eu leur rétroaction pour les apprenants, et les aiderait ainsi à améliorer l’efficacité des rétroactions qu’ils donnent. Cependant, pour mettre en place ce processus de manière optimale, il faut tenir compte des préoccupations qu’ont les résidents quant au déséquilibre de pouvoir, aux répercussions sur leur relation avec le superviseur et à l’appui de l’établissement.

The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does"). The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how"); however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Miller's conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the "does" level. Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of "doing" in practice (the "does" level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level "trusted" to the apex of Miller's pyramid.

Spaced education is a learning strategy to improve knowledge acquisition and retention. To date, no robust evidence exists to support the utility of spaced education in the Family Medicine residency. We aimed to test whether alerts to encourage spaced education can improve clinical knowledge as measured by scores on the Canadian Family Medicine certification examination. Method: We conducted a cluster randomized controlled trial to empirically and pragmatically test spaced education using two versions of the Family Medicine Study Guide mobile app. 12 residency training programs in Canada agreed to participate. At six intervention sites, we consented 335 of the 654 (51%) eligible residents. Residents in the intervention group were sent alerts through the app to encourage the answering of questions linked to clinical cases. At six control sites, 299 of 586 (51%) residents consented. Residents in the control group received the same app but with no alerts. Incidence rates of case completion between trial arms were compared using repeated measures analysis. We linked residents in both trial arms to their knowledge scores on the certification examination of the College of Family Physicians of Canada. Results: Over 67 weeks, there was no statistically significant difference in the completion of clinical cases by participants. The difference in mean exam scores and the associated confidence interval did not exceed the pre-defined limit of 4 percentage points. Conclusion: Further research is recommended before deploying spaced educational interventions in the Family Medicine residency to improve knowledge.

Purpose: Adopting CBME is challenging in medicine. It mandates a change in processes and approach, ultimately a change in institutional culture with stakeholders ideally embracing and valuing the new processes. Adopting the transformational change model, this study describes the shift in assessment culture by Academic Advisors (AAs) and preceptors over three years of CBME implementation in one Department of Family Medicine. Methods: A qualitative grounded theory method was used for this two-part study. Interviews were conducted with 12 AAs in 2013 and nine AAs in 2016 using similar interview questions. Data were analyzed through a constant comparative method. Results: Three overarching themes emerged from the data: (1) specific identified shifts in assessment culture, (2) factors supporting the shifts in culture, and (3) outcomes related to the culture shift. Conclusions: In both parts of the study, participants noted that assessment took more time and effort. In Part 2, however, the effort was mitigated by a sense of value for all stakeholders. With support from the mandate of regulatory bodies, local leadership, department, faculty development and an electronic platform, a cultural transformation occurred in assessment that enhanced learning and teaching, use of embedded standards for performance decisions, and tracking and documentation performance.

The citation of philosophers in common law judicial decision-making has been rarely explored. Yet this issue divided two American commentators: Rao, in 1998, critiqued the United States Supreme Court’s (USSC) citation of philosophers, labelling it a ‘backdoor method for judicial policy making’; Brooks, in 2003, offered a trenchant rejoinder, arguing that philosophy is potentially an ‘ally in the pursuit of sensible legal reasoning’. As issues of the curial use of exogenous or extra-legal knowledge are not settled, there is value in reflecting on Australian judicial practice. This article proceeds in three stages. First, it locates Rao’s analysis of the USSC’s citation of philosophers within a larger picture that concerns issues of citation analysis. Second, it critiques Rao’s definitions of philosophy and adjudication in terms of three ‘antipodal pairs’ of characteristics – pragmatism versus abstraction, institutionalism versus intellectualism, and precedent versus permeability. Third, rejecting R...

This article locates ‘legal history turns’ in the wider intellectual landscape of the proliferation of turns in the 20th and 21st centuries, and examines the tension between turns’ diverse topics and optics. These ‘optics’ represent diverse historiographical and interdisciplinary perceptions that illuminate topics in law, legal scholarship and legal history. The article first ‘defines’ legal history turns, and then moves to consider how the increasing production of turns generates tensions not only between topics and optics, but between brighter views and darker visions of ‘turn talk’. The potential of exploring legal history turns is endorsed by identifying how optics are generated from the topics of the ‘Legal History Turns’ Special Issue.

To examine the perspectives of family medicine preceptors and residents, including their interest and intent to participate in and their knowledge and willingness to teach or learn about medical assistance in dying (MAID).Two anonymous surveys were distributed via e-mail using a Dillman approach to residents and preceptors. Responses were collected between August 23 and November 29, 2016. Data were analyzed using descriptive and inferential statistics.The large, 4-site Queen's University family medicine residency program in southeastern Ontario.A total of 71 preceptors and 62 residents.Physician and resident knowledge of and experience, comfort, and confidence with MAID; willingness to participate in MAID; perspectives on the effect of MAID on team relationships; and the importance, desired content, and delivery of MAID education.Overall, 45.2% of preceptors and 33.3% of residents responded. A low proportion of both preceptors and residents felt competent or comfortable discussing and exploring MAID with a patient, with preceptors feeling significantly more competent and comfortable than residents (Family medicine preceptors and residents are willing and want to learn about MAID. Our research demonstrates a need to integrate MAID into the family medicine residency curriculum, with faculty development and continuing professional development for preceptors.

Background Arrhythmias are a leading cause of death in adults with congenital heart disease (ACHD). While 24-48-hour monitors are often used to assess arrhythmia burden, extended continuous ambulatory rhythm monitors (ECAM) can record 2 weeks of data. The utility of this device and the arrhythmia burden identified beyond 48-hour monitoring have not been evaluated in the ACHD population. Additionally, the impact of ECAM has not been studied to determine management recommendations. Objective To address the preliminary question, we hypothesized that clinically significant arrhythmias would be detected on ECAM beyond 48 hours and this would lead to clinical management changes. Methods A single center retrospective cohort study of ACHD patients undergoing ECAM from June 2013 to May 2016 was performed. The number and type of arrhythmias detected within and beyond the first 48 hours of monitoring were compared using Kaplan-Meier curves and Cox proportional hazard models. Results Three hundred fourteen patients had monitors performed [median age 31 (IQR 25-41) years, 61% female). Significant arrhythmias were identified in 156 patients (50%), of which 46% were noted within 48 hours. A management change based on an arrhythmia was made in 49 patients (16%). Conclusions ECAM detects more clinically significant arrhythmias than standard 48-hour monitoring in ACHD patients. Management changes, including medication changes, further testing or imaging, and procedures, were made based on results of ECAM. Recommendations and guidelines have been made based on arrhythmias on 48-hour monitoring; the predictive ability and clinical consequence of arrhythmias found on ECAM are not yet known.

The use of portfolios in postgraduate medical residency education to support competency development is increasing; however, the processes by which these assessment systems are designed, implemented, and maintained are emergent. The authors describe the needs assessment, development, implementation, and continuing quality improvement processes that have shaped the Portfolio Assessment Support System (PASS) used by the postgraduate family medicine program at Queen's University since 2009. Their description includes the impetus for change and contextual realities that guided the effort, plus the processes used for selecting assessment components and developing strategic supports. The authors discuss the identification of impact measures at the individual, programmatic, and institutional levels and the ways the department uses these to monitor how PASS supports competency development, scaffolds residents' self-regulated learning skills, and promotes professional identity formation. They describe the "academic advisor" role and provide an appendix covering the portfolio elements. Reflection elements include learning plans, clinical question logs, confidence surveys, and reflections about continuity of care and significant incidents. Learning module elements cover the required, online bioethics, global health, and consult-request modules. Assessment elements cover each resident's research project, clinical audits, presentations, objective structured clinical exam and simulated office oral exam results, field notes, entrustable professional activities, multisource feedback, and in-training evaluation reports. Document elements are the resident's continuing medical education activities including procedures log, attendance log, and patient demographic summaries.The authors wish to support others who are engaged in the systematic portfolio-design process or who may adapt aspects of PASS for their local programs.

Supplemental Digital Content is available in the text., Problem An emerging priority in medical education is the need to facilitate learners’ acquisition of quality improvement (QI) competencies. Accreditation bodies in both Canada and the United States have included QI and patient safety in their core competencies. Approach In 2010, the Department of Family Medicine at Queen’s University designed a graduate medical education curriculum to engage residents in a clinical QI program that would meet accreditation requirements. Monthly didactic sessions were combined with an experiential, team-based QI project that aligned with existing clinic priorities. The curriculum spans the first year of residency and is divided into three stages: (1) Engaging, (2) Understanding, and (3) Improving and translating. In Stage 1, teams of residents select a clinical QI topic, engage stakeholders, and collect baseline data related to their topic. In Stage 2, they focus on understanding their problem, interpreting their results, and applying QI tools. In Stage 3, they develop change ideas, translate their knowledge, and prepare to hand over their project. Outcomes This QI curriculum aided residents in effectively acquiring QI competencies and allowed them to experience real-world challenges, such as securing project buy-in, negotiating with peers, and developing solutions to problems. Unlike in many QI programs, residents learned how to improve quality rather than about QI; thus, they formed the necessary foundation to carry out QI work in the future. Next Steps The curriculum will be evaluated using a knowledge assessment and satisfaction tool and postproject resident interviews. Facilitators will focus more on improving faculty develop ment in QI.

In the context of the High Court’s alienage jurisprudence, this article examines whether future generations would fall beyond a constitutional concept of alienage, or within a claimed constitutional concept of citizenship or even nationality. Australian future generations as future citizens are critical to the endurance of the Australian polity. In this article, their constitutional relevance, but definitional ambiguity, is first overviewed, and then the limits of Australian citizenship and alienage are canvassed. This is expanded by examining the tensions between legal versus normative citizenship (dubbed the ‘citizenship dilemma’), and statutory citizenship versus constitutional alienage. The analysis then proceeds to the High Court’s identification, and later rejection, of a ‘non-citizen nonalien’ status. The contested nature of this status prompts the suggestion that it could be formally conscripted to describe future generations’ ‘non-citizen non-alien’ character. The value of this conscription is un...

This article was migrated. The article was marked as recommended. Background: To understand Canadian family medicine programs directors' perspective on the incorporation of leadership skills development in curriculum. Methods: Semi-structured interviews based on CanMEDS Leader role competencies were conducted and audio recorded. Recordings were transcribed and analyzed by two independent researchers using an interpretive approach to thematic analysis. Results: Eight interviews were conducted. All participants indicated that leadership development in family medicine residency education was important. There were varying levels of leadership development at all institutions. Barriers to incorporating leadership development included curricular time, suitable teaching skills of faculty and cost. Important factors to consider in developing curricula included approaching the subject collaboratively and offering a variety of levels of engagement. Of the 22 Key Concepts in the CanMEDS Leader Role, three were not referenced by participants: complexity of systems, effective committee participation, and information technology for healthcare. Participants offered three concepts that were not included in the CanMEDS list: communication, teamwork and research skills. Conclusions: There were varying levels of incorporation of leadership skills development into family medicine training. A clearer understanding of each of the leader competencies is needed by educational leaders in order to identify and prioritize the skills to include in family medicine residency programs. This study contributes to the knowledge of what leadership skills should be incorporated into family medicine programs.

Objective The purpose of this study was 2-fold: (1) to explore the transfer of responsibility of medical tasks from parent to child during the transition to adolescence, and (2) to examine the associations between family functioning and medical adherence in youth with spina bifida. Methods Seventy families of children with spina bifida participated in this study. Data were collected during family interaction sessions by using questionnaires completed by mothers, fathers, youth, teachers and health professionals. Results Findings suggest that responsibility for medical regimens transfers gradually from parent to child over time. Additionally, family conflict and cohesion were correlated with medical adherence. Finally, family conflict over medical issues was related to a decrease in medical adherence over time. Conclusions Results suggest that as youth take more responsibility over their medical regimens, family conflict regarding medical issues becomes a contributor to their adherence behaviors. Interventions that target family conflict may facilitate adherence behaviors.

In 2009-2010, the postgraduate residency training program at the Department of Family Medicine, Queen's University, wrestled with the practicalities of competency-based medical education (CBME) implementation when its accrediting body, the College of Family Physicians of Canada, introduced the competency-based Triple C curriculum.The authors used a stepwise approach to implement CMBE; the steps were to (1) identify objectives, (2) identify competencies, (3) map objectives and competencies to learning experiences and assessment processes, (4) plan learning experiences, (5) develop an assessment system, (6) collect and interpret data, (7) adjust individual residents' training programs, and (8) distribute decisions to stakeholders. The authors also note overarching processes, costs, and facil itating factors and processes or steps that would have been helpful for CBME implementation.Early outcomes are encouraging. Residents are being directly observed more often with increased documented feedback about performance based on explicit competency standards (24,000 data points for 150 residents from 2013 to 2015). These multiple observations are being collated in a way that is allowing the identification of patterns of performance, red flags, and competency development trajectory. Outliers are being identified earlier, resulting in earlier individualized modification of their residency training program.The authors will continue to provide and refine faculty development, are developing an entrustable professional activity field note app for handheld devices, and are undertaking research to explore what facilitates learners' competency development, what increases assessors' confidence in making competence decisions, and whether residents are better trained as a result of CBME implementation.

Assessing entrustable professional activities (EPAs), or carefully chosen units of work that define a profession and are entrusted to a resident to complete unsupervised once she or he has obtained adequate competence, is a novel and innovative approach to competency-based assessment (CBA). What is currently not well described in the literature is the application of EPAs within a CBA system. In this article, the authors describe the development of 35 EPAs for a Canadian family medicine residency program, including the work by an expert panel of family physician and medical education experts from four universities in three Canadian provinces to identify the relevant EPAs for family medicine in nine curriculum domains. The authors outline how they used these EPAs and the corresponding templates that describe competence at different levels of supervision to create electronic EPA field notes, which has allowed educators to use the EPAs as a formative tool to structure day-to-day assessment and feedback and a summative tool to ground competency declarations about residents. They then describe the system to compile, collate, and use the EPA field notes to make competency declarations and how this system aligns with van der Vleuten's utility index for assessment (valid, reliable, of educational value, acceptable, cost-effective). Early outcomes indicate that preceptors are using the EPA field notes more often than they used the generic field notes. EPAs enable educators to evaluate multiple objectives and important but unwieldy competencies by providing practical, manageable, measurable activities that can be used to assess competency development.

This article describes the indications for and the purpose and performance of the upper limb functional capacity evaluation (FCE) for persons who have sustained flexor tendon injury. It begins with the essential foundation concepts such as the U.S. Department of Labor Physical Demand Characteristics of Labor that clinicians use worldwide. The article explains how the clinician forms the plan for each FCE and the essential components that each FCE includes. While variation in the impact of upper limb injury makes a set format for performing the upper limb FCE impossible, even with a specific diagnosis, a general FCE outline with multiple options is presented. A discussion about relevant modifications to maximise function follows the identification of the critical factors to evaluate with flexor tendon injury. Importantly, the article provides insight into controversial issues such as assessment of endurance and inconsistent or sub-maximum effort. It addresses the challenge of documentation and report writing, and concludes with the issue of FCE validity.

Static progressive splinting is the use of inelastic components to apply torque to a joint in order to statically position it as close to end range as possible. It maximizes total end-range time, thus increasing passive range of motion. As tissue lengthens in response to this carefully applied stress, the clinician or wearer adjusts the joint position to progress tissue at the new maximum tolerable length. Static progressive splinting combines precision in joint position and torque application with patient-controlled stress to create an approach powerful enough to succeed when no other treatment approach does. This article discusses static progressive splinting indications, contraindications, and advantages as well as guidelines for a splinting regimen. It offers many examples of static progressive splinting and makes clear that this approach can be used with any mobilizing splint design. The unique mechanics of this splinting approach are described, and the various methods of achieving static progressive splinting are compared. Offering high levels of patient satisfaction and compliance, static progressive splinting has come to the forefront of clinical practice.

To explore conceptions of continuity of care among family physicians in traditional practices, family medicine-trained physicians working in episodic care, and family medicine residents to better understand the emotional effects on physicians of establishing long-term relationships with patients as a starting point for developing a tool to measure the qualitative connections between physicians and their patients.Qualitative descriptive study using focus groups.Traditional family practice, family medicine residency training, and episodic-care settings in Kingston, Ont.Three groups of first-year family medicine residents (n = 18), 2 groups of family physicians in established traditional practice (n = 9), and 2 groups of family physicians working in episodic-care settings (n = 10).Using focus groups, a semistructured discussion guide, and a phenomenologic approach, we explored residents' and practising physicians' conceptions about continuity of care, predominantly exploring the emotional effects on physicians of providing care for a group of patients over time.Providing care for patients over time and developing a deep knowledge of, and often a deep connection to, patients affected physicians in various ways. Most of these effects were rewarding: feelings of connection, trust, curiosity, enhanced professional competence (diagnostically and therapeutically), personal growth, and being cared for and respected. Some, however, were distressing: anxiety, grief, frustration, boundary issues, and negative effects on personal life.Family physicians experience myriad emotions connected with providing care to patients. Knowledge of what physicians find rewarding from their long-term connections with patients, and of the difficulties that arise, might be useful in further understanding interpersonal continuity of care and the therapeutic relationship, and in informing resident education about developing therapeutic relationships, evaluating resident educational experiences with continuity of care, and addressing physician burnout.

Background Recognizing the growing demand from medical students and residents for more comprehensive global health training, and the paucity of explicit curricula on such issues, global health and curriculum experts from the six Ontario Family Medicine Residency Programs worked together to design a framework for global health curricula in family medicine training programs. Methods A working group comprised of global health educators from Ontario's six medical schools conducted a scoping review of global health curricula, competencies, and pedagogical approaches. The working group then hosted a full day meeting, inviting experts in education, clinical care, family medicine and public health, and developed a consensus process and draft framework to design global health curricula. Through a series of weekly teleconferences over the next six months, the framework was revised and used to guide the identification of enabling global health competencies (behaviours, skills and attitudes) for Canadian Family Medicine training. Results The main outcome was an evidence-informed interactive framework http://globalhealth.ennovativesolution.com/ to provide a shared foundation to guide the design, delivery and evaluation of global health education programs for Ontario's family medicine residency programs. The curriculum framework blended a definition and mission for global health training, core values and principles, global health competencies aligning with the Canadian Medical Education Directives for Specialists (CanMEDS) competencies, and key learning approaches. The framework guided the development of subsequent enabling competencies. Conclusions The shared curriculum framework can support the design, delivery and evaluation of global health curriculum in Canada and around the world, lay the foundation for research and development, provide consistency across programmes, and support the creation of learning and evaluation tools to align with the framework. The process used to develop this framework can be applied to other aspects of residency curriculum development.

Feature Editor's Note: For various reasons — including that stu- dents resist or don't like them — writing assignments are not used frequently in health curriculums. This study examines PA students' attitudes regarding an applied writing assignment that is incor- porated into a basic biomedical course. While the results from this study repre- sent a single assignment at one pro- gram, they do encourage PA faculty to reconsider the benefit and satisfaction levels that may be associated with writ- ing assignments. Purpose: The purpose of this study was to evaluate first-year physician assistant (PA) stu- dents' attitudes towards an applied writing assignment in a basic biomedical course. Methods: The assignment required the students to choose a physiology or pathophysiolo- gy-related article from a respected media outlet and to select a related original research article. The students summarized, compared, and contrasted the two articles. Finally, the students described how they would explain the media article and related research article to a patient in lay terms that the patient could understand. To evaluate the effectiveness of this assignment the students were given an anonymous survey. Results: The majority of students agreed that this assignment was relevant to their career training, that the articles they chose were related to an interest of theirs, and that they learned new information about health and/or pathophysiology. Students' comments reinforced their perceived sig- nificance of this assignment to their career training and roles as future health care profes- sionals. Conclusions: It can be inferred from this study that PA students found this type of writing assignment helpful for independently learning a course topic of interest and that they found the writing exercise applicable to their future careers.

The authors describe curricular modifications created in response to the changing culture of medical education, thealth care systems, academic medicine, and generational differences. The authors propose a model child psychiatry inpatient curriculum that is sustainable within a community teaching hospital in the 21st century. The authors built upon the existing literature in health care financing, academic medicine, effective leadership, and the collective clinical, educational and administrative experience of its faculty to design a model inpatient curriculum that should be portable to other training programs. An innovative training model was developed, implemented, and improved over a 5-year period without any additional fiscal resources. This training model has the potential to improve patient care, resident training, interdisciplinary functioning, and resident satisfaction.

To assess whether computer use by physicians during the patient-physician encounter influences patient satisfaction in a family medicine teaching centre.Cross-sectional mailed survey.Queen's University Family Medicine Centre in Kingston, Ont.A random sample of 300 patients from the family medicine centre, all of whom were older than 18 years of age and had visited their family physicians in the past year.Patient preference for or against computer use by the physician and effect of computer use on various aspects of patient-physician interaction.The response rate was 58.3%. Most respondents (51.4%) had no preference about computer use in the office, and most (88.0%) were either "very satisfied" or "satisfied" with their visits. When assessing the influence of patient and visit characteristics on computer preference, only the "doctor's attitude toward computer use" had a positive correlation with patient preference (P=.0012). Respondents were most likely to indicate "positive" or "very positive" effects of computer use on all aspects of the patient-physician interaction, except "level of distraction of the doctor" and "time spent chatting about nonmedical matters," which were most commonly reported as being unaffected by computer use. Specifically, 57.1% of respondents thought that computer use had either a "positive" or "very positive" effect on their overall satisfaction with their visits, with another 30.3% believing there was no effect.Most patients expressed no preference for whether or not computers were used in their physicians' offices, although computers did seem to have a positive effect on overall satisfaction with visits. Doctors' attitudes toward computer use influenced their patients' preferences.

In the age of educational accountability, both the district and the school are held accountable for improving the academic achievement of each student, thus compelling both to implement reforms that demonstrate measurable increases in student achievement. The changes in accountability measures have revived interest in the district office's role in educational change and reform. Although elementary schools, and to a lesser degree middle schools, seem to be rising to the challenge of standards- based education, high schools are lagging behind. Though the research base is growing, more needs to be learned, specifically about instructional practice reform at the high school level, to identify the successful interactions between the school site and the district office, both charged with undertaking the improvement effort. Acting as a participant observer, the researcher's major goal of the study is to identify and examine the role of the district office in supporting or constraining instructional practice reform at the high school level. It has been suggested that districts can and should collect and analyze data from a variety of sources to make decisions that support teaching and learning. By examining one secondary district's reform efforts targeted at instructional practice, the study will contribute to the small yet growing body of research on the role of the district office in high school reform. In addition, participant observer methodology has the potential for administrators to generate knowledge out of their own practice settings

Because the evaluation of an injured person’s ability to lift has such influence on the final return-to-work determination, therapists performing these evaluations require a thorough knowledge of upper extremity factors during lifting. Although volumes of information exist concerning low back and trunk factors during manual materials handling, little literature is currently available relating the hand and arm to lifting. This article reviews the literature to provide therapist-evaluators with crucial perspectives and information on critical factors of the upper extremity in lifting. Ergonomic, biomechanic, physiologic and psychophysical approaches are presented with an eye toward the development of a lifting evaluation that comprehensively assesses upper extremity function during manual materials handling. The article provides examples of evaluations currently in use and makes recommendations for documentation of the lifting evaluation.

Background In a study to determine the site and preceptor characteristics most valued by clerks and residents in the ambulatory setting we wished to confirm whether these would support effective learning. The deep approach to learning is thought to be more effective for learning than surface approaches. In this study we determined how the approaches to learning of clerks and residents predicted the valued site and preceptor characteristics in the ambulatory setting. Methods Postal survey of all medical residents and clerks in training in Ontario determining the site and preceptor characteristics most valued in the ambulatory setting. Participants also completed the Workplace Learning questionnaire that includes 3 approaches to learning scales and 3 workplace climate scales. Multiple regression analysis was used to predict the preferred site and preceptor characteristics as the dependent variables by the average scores of the approaches to learning and perception of workplace climate scales as the independent variables. Results There were 1642 respondents, yielding a 47.3% response rate. Factor analysis revealed 7 preceptor characteristics and 6 site characteristics valued in the ambulatory setting. The Deep approach to learning scale predicted all of the learners' preferred preceptor characteristics (β = 0.076 to β = 0.234, p < .001). Valuing preceptor Direction was more strongly associated with the Surface Rational approach (β = .252, p < .001) and with the Surface Disorganized approach to learning (β = .154, p < 001) than with the Deep approach. The Deep approach to learning scale predicted valued site characteristics of Office Management, Patient Logistics, Objectives and Preceptor Interaction (p < .001). The Surface Rational approach to learning predicted valuing Learning Resources and Clinic Set-up (β = .09, p = .001; β = .197, p < .001). The Surface Disorganized approach to learning weakly negatively predicted Patient Logistics (β = -.082, p = .003) and positively the Learning Resources (β = .088, p = .003). Climate factors were not strongly predictive for any studied characteristics. Role Modeling and Patient Logistics were predicted by Supportive Receptive climate (β = .135, p < .001, β = .118, p < .001). Conclusion Most site and preceptor characteristics valued by clerks and residents were predicted by their Deep approach to learning scores. Some characteristics reflecting the need for good organization and clear direction are predicted by learners' scores on less effective approaches to learning.