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Background: While many Area of Focused Competency (AFC) Diplomas are available to those who have completed Pediatric residency training, it is not known which competencies are enhanced within each AFC discipline. Our objective was to determine which CanMEDS roles were targeted by existing AFCs available to those who have completed Pediatric residency training and identify gaps within CanMEDs roles that may be fulfilled by the development of new AFCs., Methods: A qualitative study was undertaken using document analysis methodology to compare CanMEDS competencies across AFCs available to those with Royal College examination eligibility or certification in Pediatrics. RCPSC Competency Training Requirements documents were used to compare and contrast the competencies in each AFC with competencies established in Pediatric residency training. Key and Enabling Competencies were compared for each CanMEDS role to identify differences., Results: Ten AFCs were identified with eligibility requirements including Royal College examination eligibility or certification in Pediatrics. All 10 AFCs included at least one new Medical Expert competency, for a total of 42 unique competencies in this role across all AFCs. The Scholar role had only 10 new competencies across seven AFCs, while only one AFC added a single unique competency in the Collaborator role., Conclusions: The majority of new competencies contributed by AFCs lie within the CanMEDS role of Medical Expert. The Scholar and Collaborator roles have the least differences when comparing competencies of existing AFCs to those competencies established in Pediatric residency training. Developing additional AFCs that offer advanced skills in these roles may help close this gap within the discipline of Pediatrics., Competing Interests: None of the authors have any conflicts of interest due to financial or personal relationships that could potentially bias their work., (© 2023 Agarwal, Conejero Muller, Atkinson, Bismilla; licensee Synergies Partners.)

Background: Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed., Objective: To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication., Design: Prospective Type 2 Hybrid effectiveness implementation study., Settings and Participants: Residents from diverse specialties across 32 hospitals (12 community, 20 academic)., Intervention: External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews., Main Outcome and Measures: Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality., Results: 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic)., (© 2022 Society of Hospital Medicine.)

Background: High-stakes conversations are frequent in Medical Genetics. News shared is often perceived as "bad" and can lead to patient hostility. Breaking bad news (BBN) is therefore a challenging clinical task for physicians and is often included as a foundational skill in medical education. The methods of teaching this skill are variable, with no widely accepted standard. We propose the use of simulation as a safe and effective training tool., Approach: Medical Genetics residents participated in a 4-week curriculum on BBN and de-escalating patient hostility and anger. The curriculum consisted of (1) a standardised patient simulation scenario requiring the disclosure of abnormal prenatal test result to a hostile patient, (2) coaching and feedback by genetic counsellors (GCs), (3) reflective exercises, and (4) workshops on de-escalation techniques. Trainees completed a postsimulation survey and postencounter reflection forms. Written comments on the survey and the reflections were analysed for themes., Evaluation: Six junior and four senior residents participated in this curriculum innovation. Analysis of reflections revealed that simulation coupled with the genetic counsellor's (GC) timely feedback and reflection exercise were good education strategies for practicing BBN and de-escalation techniques in a challenging counselling situation. Most of the trainees felt that this teaching approach was successful and should be used for future training., Implications: Simulation can help prepare Medical Genetics trainees deliver difficult news and successfully de-escalate a hostile patient encounter. Consideration should be given to counselling and de-escalation simulations as a useful addition to standing curricula for Medical Genetics trainees., (© 2022 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Direct observation of clinical skills is central to assessment in a competency-based medical education model, yet little is known about how direct observation is experienced by trainees and observers. The objective of the study is to explore how direct observation was experienced by residents and faculty in the context of the I-PASS Handoff Study. In this multi-center qualitative study, we conducted focus groups and semi-structured interviews of residents and faculty members at eight tertiary pediatric centers in North America that implemented the I-PASS Handoff Bundle. We employed qualitative thematic analysis to interpret the data. Barriers to and strategies for direct observation were described relating to the observer, trainee, and clinical environment. Residents and faculty described a mutual awareness that residents change their performance of handoffs when observed, in contrast to their usual behavior in a clinical setting. Changes in handoff performance may depend on the nature of the observer or 'audience'. Direct observation also highlighted the importance of handoffs to participants, recognized as a clinical activity that warrants feedback and assessment. Dramaturgical theory can be used to understand our finding of 'front-stage' (observed) versus 'backstage' (unobserved) handoffs as distinct performances, tailored to an "audience". Educators must be cognizant of changes in performance of routine clinical activities when using direct observation to assess clinical competence.

Background: The I-PASS Handoff Study found that introduction of a handoff bundle (handoff and teamwork training for residents, a mnemonic, a handoff tool, a faculty development program, and a sustainability campaign) at 9 pediatrics residency programs was associated with improved communication and patient safety., Objective: This parallel qualitative study aimed to understand resident experiences with I-PASS and to inform future implementation and sustainability strategies., Methods: Resident experiences with I-PASS were explored in focus groups (N = 50 residents) at 8 hospitals throughout 2012-2013. A content analysis of transcripts was conducted following the principles of grounded theory., Results: Residents generally accepted I-PASS as an ideal format for handoffs, and valued learning a structured approach. Across all sites, residents reported full adherence to I-PASS when observed, but selective adherence in usual practice. Residents adhered more closely when patients were complex, teams were unfamiliar, and during evening handoff. Residents reported using elements of the I-PASS mnemonic variably, with Illness Severity and Action Items most consistently used, but Synthesis by Receiver least used, except when observed. Most residents were receptive to the electronic handoff tool, but perceptions about usability varied across sites. Experiences with observation and feedback were mixed. Concern about efficiency commonly influenced attitudes about I-PASS., Conclusions: Residents generally supported I-PASS implementation, but adherence was influenced by patient type, context, and individual and team factors. Our findings could inform future implementation, particularly around the areas of resident engagement in change, sensitivity to resident level, perceived efficiency, and faculty observation., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Entrustable professional activities (EPAs) provide a framework to standardize medical education outcomes and advance competency-based assessment. Direct observation of performance plays a central role in entrustment decisions; however, data obtained from these observations are often insufficient to draw valid high-stakes conclusions. One approach to enhancing the reliability and validity of these assessments is to create videos that establish performance standards to train faculty observers. Little is known about how to create videos that can serve as standards for assessment of EPAs.The authors report their experience developing videos that represent five levels of performance for an EPA for patient handoffs. The authors describe a process that begins with mapping the EPA to the critical competencies needed to make an entrustment decision. Each competency is then defined by five milestones (behavioral descriptors of performance at five advancing levels). Integration of the milestones at each level across competencies enabled the creation of clinical vignettes that were converted into video scripts and ultimately videos. Each video represented a performance standard from novice to expert. The process included multiple assessments by experts to guide iterative improvements, provide evidence of content validity, and ensure that the authors successfully translated behavioral descriptions and vignettes into videos that represented the intended performance level for a learner. The steps outlined are generalizable to other EPAs, serving as a guide for others to develop videos to train faculty. This process provides the level of content validity evidence necessary to support using videos as standards for high-stakes entrustment decisions.

Background: The Royal College of Physicians and Surgeons of Canada (RCPSC) objectives for training in pediatrics include 26 procedural skills, 11 of which are included in the final in-training evaluation report (FITER). The importance of each procedure for practice and the preparedness of pediatric residency graduates to perform these procedures are not known., Methods: A questionnaire was distributed to all pediatric residency program directors and members of the RCPSC Specialty Committee in Pediatrics (N = 21) in October 2010, requesting them to rate the perceived importance and preparedness of graduating pediatric residents in all procedural skills on a 5 point Likert scale, as well as the presence of a curriculum and documentation for each procedure. Mean importance and preparedness were calculated for each procedure., Results: Response rate was 16/21 (76 %). Perceived preparedness was significantly lower than importance for the majority of procedures (p < 0.05). Ten procedures had a high mean importance rating (>3) but a low mean preparedness rating (<3). Presence of a curriculum and documentation for procedures varied across centers, and their presence was correlated with both perceived importance and preparedness (p < 0.0001)., Conclusions: Many procedures in which pediatric residents are required to be competent by the RCPSC are felt to be important. Residents are not felt to be adequately prepared in several of the required procedures by the time of graduation. Procedures with high ratings of importance but low preparedness ratings should be targeted for curricular interventions.

Background and Objective: Medical education relies heavily on workplace learning where trainees are educated through their clinical experience. Few studies have explored trainees' perceptions of the educational value of these patient care experiences. The aim of this study was to identify pediatric patient characteristics that medical trainees perceive as educationally valuable., Methods: Over 2 months, trainees on pediatric inpatient wards ranked the perceived educational value of patients under their care on a 4-point bipolar Likert scale. Three patient characteristics were examined: complex-chronic and noncomplex-chronic preexisting conditions, difficult social circumstances, and rare diseases. Patient-level predictors of cases perceived as educationally valuable (defined as scores≥3) were examined by using univariate and multivariate analyses., Results: A total of 325 patients were rated by 51 trainees (clinical medical students [45%], first-year residents [29%], third-year residents/fellows [26%]). Rare diseases had a higher educational value score (adjusted odds ratio 1.76, 95% confidence interval 1.08-2.88, P=.02). Complex-chronic and noncomplex-chronic preexisting conditions and difficult social circumstances did not affect the perceived educational value., Conclusions: Trainees attribute the most educational value to caring for patients with rare diseases. Although trainees' perceptions of learning do not necessarily reflect actual learning, they may influence personal interest and limit learning from an educational experience. Knowledge of trainee perceptions of educational experience therefore can direct medical educators' approaches to inpatient education., (Copyright © 2015 by the American Academy of Pediatrics.)

Background: Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking., Methods: We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events., Results: In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time., Conclusions: Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Background: On July 1, 2009, in Ontario the maximum period of continuous duty that residents were permitted to work was reduced from 28 to 24 hours. We evaluated the effect of regulation on residents in 3 eras: 2 before (2005 and early 2009) and 1 after (late 2009) the duty-hour reduction., Methods: On-call pediatric residents on pediatric medicine rotations prospectively recorded the numbers of patients (assigned and admitted) and the durations of direct patient care, documentation, staff supervision, and education attended. Sleep was measured with actigraphy., Results: The 51 residents worked 180 duty periods, were assigned a median of 6 (interquartile range: 4 -12) daytime patients and 24 (interquartile range: 19-30) overnight patients. Residents reported spending means of 239 minutes providing direct patient care, 235 minutes documenting, and 243 minutes sleeping and receiving 73 minutes of staff supervision and 52 minutes of education. From early 2009 to after duty-hour reduction, residents provided 47 fewer (19.6%) minutes of direct patient care (P = .056) and received 44 fewer minutes (60.3%) of supervision (P = .0005) but spent similar times documenting, receiving education, and sleeping. In early 2009, residents provided 73 more minutes (30.5%) of direct patient care (P = .0016), spent 63 more minutes (26.8%) documenting, and slept 105 fewer minutes (43.0%) (P = .0062) than in 2005., Discussion: After duty-hour reduction in 2009, we found reduced supervision and direct patient care. Comparison of the 2 periods before duty-hour reduction showed less sleep and longer patient contact in early 2009, which suggests that changes occurred without regulation.