This case study examines the emergence of an autonomy-oriented assessment culture in Pediatric residency education in the School of Medicine at Queen’s University. Through a case study approach this research explores how an assessment system to capture residents’ performance in the clinical environment was initiated, how that process supported a shift in assessment cultural, and how assessment innovation is eclipsing departmental boundaries. The case has instrumental value in illuminating how an autonomy-oriented assessment system and culture can be cultivated in residency education. The analytic frame for the case was constructed based on research literature that identified weaknesses in assessment practices in residency education more generally. The approach was theoretical, with the intent to explain how a shift in assessment culture is emerging in Pediatrics. A longitudinal approach was adopted to expose shifts in the culture. The narrative structure distills the journey into a manageable story. Three watershed events that exemplified change were systematically selected from data collected over a three-year period and constitute the findings of this research. The central contribution this research makes is that it is possible to shift the culture of assessment within a Pediatric residency program. That shift can be understood to unfold over a prolonged period through a process of mediating both social and regulatory requirements. Beginning to shift the assessment culture in Pediatrics was achieved by: recognizing the need for change in assessment practice, re-conceptualizing and realizing that change, and engaging and empowering the community to support a shift in assessment culture. Strong leadership, widening community engagement and the Rubric Descriptor Bank supported this process. Five theoretically informed principles guided the emergence of the autonomy-oriented assessment culture in Pediatrics including: (a) conceptualizing learning as a social, active process: (b) focusing attention on residents’ multidimensional growth; (c) moving away from a high-stakes orientation to assessment based on the false dichotomy between formative and summative assessment and embracing it as a tool for supporting and monitoring growth over time and across contexts; (d) actively supporting residents’ learning strategy and assessment skill development; and (e) fostering a growth orientation to learning, embracing the concept of graduated autonomy. / Thesis (Ph.D, Education) -- Queen's University, 2012-12-19 21:04:59.344

In Canada, residents’ views on which roles and tasks are effective to becoming a competent physician is not yet part of the research discourse. Ensuring that competency-based curriculum (CBC) objectives are aligned with competencies and evaluation methods is critical to build a curriculum that will produce competent physicians. This research reports on the residents' views of the current Orthopaedic Surgery curriculum (UofT) which is solely competency-based. The residents' views were explored about which CanMEDS Roles and Entrustable Professional Activities (EPA’s) would be important to develop for them to become competent physicians. This study employed a mixed methodology. The individual interviews were from CBC orthopaedic surgery residents and the survey respondents were orthopaedic surgery regular time-based stream and competency-based stream residents. This research provides a better understanding of the resident experience so that educational practice and residency education can influence decisions around the curriculum design in postgraduate competency-based medical education programs.

In Canada, residents’ views on which roles and tasks are effective to becoming a competent physician is not yet part of the research discourse. Ensuring that competency-based curriculum (CBC) objectives are aligned with competencies and evaluation methods is critical to build a curriculum that will produce competent physicians. This research reports on the residents' views of the current Orthopaedic Surgery curriculum (UofT) which is solely competency-based. The residents' views were explored about which CanMEDS Roles and Entrustable Professional Activities (EPA’s) would be important to develop for them to become competent physicians. This study employed a mixed methodology. The individual interviews were from CBC orthopaedic surgery residents and the survey respondents were orthopaedic surgery regular time-based stream and competency-based stream residents. This research provides a better understanding of the resident experience so that educational practice and residency education can influence decisions around the curriculum design in postgraduate competency-based medical education programs.

Clinical preceptorships that nurture virtual care competencies among family medicine residents or physicians in-training remain understudied. Guided by epistemological views of pragmatism and social constructivism, I designed and implemented a three-phase exploratory mixed-methods study to address the following research questions: • How is clinical preceptorship in virtual healthcare settings conceptualized within the field of postgraduate medical education? • What are the gaps in the way clinical preceptorship in virtual healthcare settings is conceptualized in the field of postgraduate medical education? • To what extent do preceptors involve, prepare, and assess family medicine residents in virtual healthcare settings? • How do preceptors assess and provide feedback to family medicine residents in virtual healthcare settings? In phase I, a scoping review identified 24 peer-reviewed articles (published before February 25, 2021) relevant to clinical precepting with postgraduate medical trainees in virtual healthcare settings. In a sequential manner, I then led a one-time online survey (phase II; n = 38) and key informant interviewing (phase III; n = 13) with preceptors of family medicine residents. National data confirmed that clinical precepting in virtual healthcare settings can be characterized by individual factors, preceptor-resident behaviors, and workplace artefacts. Additional insights supported preceptors’ ability to engage family medicine residents in virtual care activities, along with the constraints and strategies to supervise them effectively. Opportunities to assess competency are possible; however, preceptors identified gaps in assessment practices to identify underperformance in the virtual therapeutic frame. A key research deliverable is a thematic framework illustrating the experience of clinical precepting in virtual healthcare settings. Drawing on adaptive expertise, actor-network theory, and praxeology, the final article elucidates how this work contributes to educational solutions and research directions for competency-based family medicine education.

Canadian national survey of oncology residency program directors and trainees; randomized trial of medical education intervention / Purpose: This work addresses teaching communication skills for eliciting cardiopulmonary resuscitation (CPR) wishes, or code status discussions, with cancer patients. The objectives of this thesis include: 1) define current teaching practices for code status communication training in Canadian oncology residency programs, and 2) examine the effect of teaching a novel communication framework for code status discussions to oncology residents. Methods: All current residents and program directors in Canadian medical and radiation oncology residency programs were surveyed regarding education, perceived gaps in training, attitudes towards and patterns of clinical practice for code status discussions with cancer patients. We carried out a multicentre randomized trial to determine the effect of teaching a code status communication framework to oncology learners. Residents completed a training workshop and were evaluated in simulated patient encounters (observed structured clinical exam [OSCE]). Participants were randomized to complete the training before the OSCE (experimental arm), or after the OSCE (control arm). The primary outcome was objective rating of code status communication skills. Results: Current postgraduate oncology curricula lack formal teaching and evaluation of code status communication skills. Educators support the need for innovative teaching tools in this field. Accordingly, a novel six-step communication framework was created in which core themes were summarized by the mnemonic acronym PULSES (Prognosis, Underlying values, Long-term outcome and Short-term outcome of CPR, provision of an Educated recommendation, Summary, style and documentation). A total of 46 oncology residents from 3 training centres participated in the randomized trial. Overall, learners in the experimental group had higher mean content-specific, general communication, and global rating communication scores than those in the control group. The training program conferred the greatest benefit among junior residents. Scores across rating tools were highly correlated. Conclusions: Communication training for code status discussions in Canadian oncology residency programs is lacking. With use of a novel communication framework, we have shown that structured teaching on code status discussions can improve competence in this challenging communication task. Moreover, we have developed educational resources that can be implemented in current curricula. Building capacity for clear and effective code status communication with cancer patients will contribute to high quality end of life care in Canada. / Thesis / Master of Science (MSc) / Medical learners in oncology (cancer care) training programs often lead discussions with cancer patients about code status, that is, patients’ wishes for use or non-use of life-sustaining resuscitation interventions including CPR. Learners receive little training for these complex encounters; yet, decisions regarding resuscitation wishes can influence the quality of care received by cancer patients at end of life. In this study we conducted a survey of trainees and program directors in Canada to better understand current educational practices and attitudes towards education on this topic. Most trainees are not receiving formal teaching or evaluation, and new educational resources are needed. We then developed a 6-step communication guide for code status discussions. We studied the effect of a training workshop in which the communication guide was taught to learners in oncology. We found that the training program improved communication ability among learners with the greatest impact seen among junior learners.

INTRODUCTION: Academic half-days (AHDs) are regular teaching events that occur outside of patient care. AHDs often take the form of extended didactic lectures, despite the literature around effective teaching techniques. This may decrease residents’ ability to pay attention to the content being presented and instead promote mind wandering (defined in this thesis as self-reported task-unrelated thought). This thesis examines mind wandering during academic half-days (AHDs) in postgraduate medical training through two studies, with the overarching goal of understanding how results might inform the design of classroom-based teaching sessions in postgraduate medical education. METHODS: In the first study, a qualitative approach was used to examine residents’ perceptions about the nature of their learning experience during AHDs. Two focus groups were held with residents in hematology (n = 5) and obstetrics and gynecology (n = 15) and analyzed using a thematic analysis approach. In the second study, thought probes were administered approximately every 15 minutes during three AHD sessions in each program (hematology: n = 6 residents; obstetrics and gynecology: n = 30 residents) to quantitatively examine how three commonly-used instructional methods (didactic lecture, group discussion, and case-based learning) influenced mind wandering during AHDs. RESULTS: Findings of the qualitative study revealed differences with respect to residents’ overall perceptions of AHDs, perceptions of attention during AHDs, and motivations for learning. However, residents in both programs agreed that presenters could maximize resident engagement and learning by spending more time on case-based learning and group discussions as opposed to didactic lectures. Quantitative findings supported resident perceptions, demonstrating significantly less mind wandering during case-based learning (7%) than didactic lectures (33%). CONCLUSIONS: The findings of this work suggest that instructional method influences the amount of self-reported mind wandering during AHDs, and specifically, that case-based learning may be more effective than didactic lectures in maintaining engagement during AHDs. / Thesis / Master of Science (MSc) / Academic half-days (AHDs) are regular teaching events that occur outside of patient care. AHDs often take the form of extended didactic lectures, despite the literature around effective teaching techniques. This may decrease residents’ ability to pay attention to the content being presented and instead promote mind wandering (defined in this thesis as self-reported task-unrelated thought). This thesis examines mind wandering during AHDs, with the goal of understanding how results might inform the design of classroom-based teaching sessions in postgraduate medical education through two studies: a qualitative study examining residents’ perceptions about their learning experience during AHDs, and a quantitative study examining how three commonly-used instructional methods (didactic lecture, group discussion, and case-based learning) influenced mind wandering during AHDs. Taken together, these two studies make a contribution to the exploration of how classroom-based teaching sessions such as AHDs can be optimized to enhance student learning in postgraduate medical education.

Introduction: Competency-based medical education (CBME) is a learner-centered outcomes-based approach. Competence by Design (CBD) is a hybrid time-based and outcomes-based CBME model that was adopted by all Royal College of Physicians and Surgeons of Canada-based residency training programs, with the primary objective of enhancing postgraduate medical education quality. However, preliminary findings suggest that residents experience higher levels of stress, anxiety, and exhaustion in CBD than with previous curricula. This thesis aims to identify and understand the emotional effects of CBME on residents, faculty, and administrative staff. Methods: This study used a qualitative approach, specifically hermeneutic phenomenology. Seven residents, six faculty members (several with education leadership roles), and one administrative staff member from a postgraduate Psychiatry program were recruited. Participants underwent semi-structured, one-on-one interviews where they were probed on their emotions with CBME. Interviews were transcribed and analyzed using a line-by-line approach that generated individual meaning units and, subsequently, themes. Results: Five themes were identified: 1) Education is an emotional experience; 2) The emotional toll of CBD; 3) CBD is a failed educational promise—Expectations vs. realities; 4) Structural and administrative burdens of CBD; and 5) Survival of educational demands—The quest for coping. Participants initially struggled to articulate their emotions, but expressed surprise at realizing they did have strong, often negative, emotions related to CBD. There was also a dissonance identified between the anticipated benefits and the execution of CBD. Furthermore, participants highlighted administrative and structural challenges of CBD, specifically regarding Entrustable Professional Activities, which were a burden and lacked much educational value. Participants discussed using various coping strategies to manage CBD’s demands. Conclusion: The findings of this work suggest that CBD has a negative emotional impact on residents and faculty, specifically due to tension between CBD’s theoretical benefits and its practical challenges, including increased emotional burden and structural challenges. / Thesis / Master of Science (MSc) / Competency-based medical education (CBME) is a learner-centered outcomes-based approach. Competence by Design (CBD) is a hybrid time-based and outcomes-based CBME model that was adopted by all Royal College of Physicians and Surgeons of Canada-based residency training programs, with the primary objective of enhancing the quality of postgraduate medical education. However, preliminary findings suggest that residents experience higher levels of stress, anxiety, and exhaustion in a CBD model than with previous curricula. This thesis aims to understand the emotional effects of CBME on residents, faculty, and administrative staff in a postgraduate Psychiatry program. In this qualitative study, participants underwent semi-structured, one-on-one interviews where they were probed on their emotions and experiences with CBME. The findings suggest that CBD has a negative emotional impact on residents and faculty, specifically due to tension between CBD’s theoretical benefits and its practical challenges, including increased emotional burden and structural challenges associated with the assessment methods.

This study investigated international medical graduates (IMGs), registered between January 1, 2007 and April 14, 2011, at the Access Centre for Internationally Educated Health Professionals in Ontario. By way of logistic regression in a cross-sectional design, it was found that permanent residents who were recent immigrants had lesser chances of being employed full-time at registration (baseline). By way of survival analysis in a cohort design, it was found that younger IMGs who have been in Canada less than 5 years and who have taken the Medical Council of Canada Evaluating Exam (MCCEE) have the greatest chances of securing residency positions in Canada or the US, whereas IMGs from Eastern Europe, South Asia and Africa have lesser chances. It was revealed that registered IMGs are a vulnerable population, and certain groups may be disadvantaged due to underlying characteristics. These groups can be targeted for specific interventions.

This study investigated international medical graduates (IMGs), registered between January 1, 2007 and April 14, 2011, at the Access Centre for Internationally Educated Health Professionals in Ontario. By way of logistic regression in a cross-sectional design, it was found that permanent residents who were recent immigrants had lesser chances of being employed full-time at registration (baseline). By way of survival analysis in a cohort design, it was found that younger IMGs who have been in Canada less than 5 years and who have taken the Medical Council of Canada Evaluating Exam (MCCEE) have the greatest chances of securing residency positions in Canada or the US, whereas IMGs from Eastern Europe, South Asia and Africa have lesser chances. It was revealed that registered IMGs are a vulnerable population, and certain groups may be disadvantaged due to underlying characteristics. These groups can be targeted for specific interventions.

This study investigated international medical graduates (IMGs), registered between January 1, 2007 and April 14, 2011, at the Access Centre for Internationally Educated Health Professionals in Ontario. By way of logistic regression in a cross-sectional design, it was found that permanent residents who were recent immigrants had lesser chances of being employed full-time at registration (baseline). By way of survival analysis in a cohort design, it was found that younger IMGs who have been in Canada less than 5 years and who have taken the Medical Council of Canada Evaluating Exam (MCCEE) have the greatest chances of securing residency positions in Canada or the US, whereas IMGs from Eastern Europe, South Asia and Africa have lesser chances. It was revealed that registered IMGs are a vulnerable population, and certain groups may be disadvantaged due to underlying characteristics. These groups can be targeted for specific interventions.