Competency-Based, Time-Variable Education in the Health Professions: Crossroads

Real Patient Participation in Workplace-Based Assessment of Health Professional Trainees: A Scoping Review

The aim of this scoping review is to outline the existing landscape of how real patients participate in the workplace-based assessment of trainees across diverse healthcare professions. In 2019-2020, the authors searched MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, and Web of Science databases for studies that included descriptions of experiences whereby patients received care from a health professional trainee and participated in workplace-based assessments of that trainee. Full-text articles published in English from 2009 to 2020 were included in the search. Of the 8770 studies screened; 77 full-text articles were included. Analysis showed that strategies for patient participation in workplace-based assessment varied widely. Aspects studied ranged from validation of an assessment tool to evaluation of the impact of an educational intervention on trainees' performance. Assessment of patient satisfaction was the most common approach to patient involvement. The majority of studies were conducted in North America and in the context of physician training. Formal patient participation in the assessment of health professional trainees appears heterogeneous across health professions. Gaps in the literature are evident; therefore, this review points to an inclusive approach to workplace-based assessment to ensure patient feedback of the trainees who care for them is represented.

Facilitating flexibility in postgraduate nursing education through entrustable professional activities to address nursing shortages and career prospects

AIM

To communicate how the Dutch postgraduate nursing education landscape was redesigned using entrustable professional activities (EPAs). The goal of this initiative was to reduce training time, enhance transfer across nursing specialities and contribute to a better-aligned continuum of initial education, postgraduate education and continuing professional development.

BACKGROUND

Nursing shortages continue to worsen worldwide. An approach to address this growing shortage is to create a more flexible postgraduate training structure, offering training in the just-in-time and just-as-needed models. EPAs can be used as building blocks for training and assessment. Experience with EPAs (i.e. units of professional practice that can be entrusted once a trainee has demonstrated the required competencies) in health professions education, including nursing, is rising rapidly. While EPAs are largely used to create training flexibility within a programme, they can also be used to create flexibility across programmes. In 2018-2022, training hospitals and education institutions in the Netherlands collaborated in the CZO Flex Level Project to redesign the postgraduate nursing education landscape using EPAs.

DISCUSSION

The implementation of a flexible postgraduate nursing education model nationwide will face several challenges. An overview of these challenges and suggestions for future research on the effects of the new structure on nursing competence, satisfaction and career development are provided.

CONCLUSION

EPAs can imbue flexibility within and across training programmes. Designing an EPA-based educational landscape requires nationally coordinated efforts.

IMPLICATIONS FOR NURSING POLICY

Redesigning educational structures to allow for more flexibility is critical to address major societal challenges in healthcare.

Using Simulation-Based Mastery Learning to Achieve Excellent Learning Outcomes in Physical Therapist Education

INTRODUCTION

The 2 aims of this observational study are (a) to describe the implementation and feasibility of a bed mobility skills simulation-based mastery learning (SBML) curricular module for physical therapist students and (b) to measure learning outcomes and student perceptions of this module.

REVIEW OF LITERATURE

Simulation-based mastery learning is an outcome-based educational approach that has been successful in other health professions but has not been explored in physical therapy education.

SUBJECTS

Eighty-seven students in a single cohort of a Doctor of Physical Therapy program.

METHODS

The SBML module in this pretest-posttest study included a pretest, instruction, initial posttest, and additional rounds of instruction and assessment as needed for all learners to achieve the minimum passing standard (MPS) set using the Mastery Angoff and Patient Safety methods. Outcome measures were bed mobility assessment pass rates and scores, additional student and faculty time compared with a traditional approach, and student perceptions of their self-confidence and the module.

RESULTS

All students achieved the MPS after 3 rounds of training and assessment beyond the initial posttest. Mean Total Scores improved from 67.6% (12.9%) at pretest to 91.4% (4.8%) at mastery posttest (P < .001, Cohen's d = 1.8, 95% CI [1.4-2.1]); mean Safety Scores improved from 75.2% (16.0%) at pretest to 100.0% (0.0%) at mastery posttest (P < .001, Cohen's d = 1.5, 95% CI [1.2-1.9]). Students who did not achieve the MPS at the initial posttest (n = 30) required a mean of 1.2 hours for additional instruction and assessment. Survey results revealed an increase in student confidence (P < .001) and positive student perceptions of the module.

DISCUSSION AND CONCLUSION

Implementation of this SBML module was feasible and resulted in uniformly high levels of bed mobility skill acquisition. Based on rigorous learning outcomes, feasible requirements for implementation, and increased student confidence, SBML offers a promising approach for wider implementation in physical therapy education.

Clinical leadership in nursing homes: A qualitative study of healthcare professionals' perspectives on concept and characteristics

AIM(S)

To conceptualise and identify characteristics of clinical leadership in the nursing home setting.

DESIGN

A qualitative study using semi-structured focus group interviews and a thematic analysis.

METHODS

Five semi-structured focus group interviews were conducted with 41 healthcare professionals from nursing and other healthcare disciplines working in nursing homes (such as nurse assistants, licensed practical nurses, registered nurses (RNs), occupational therapists, recreational therapists, psychologists and gerontologists). Qualitative thematic content analysis of the gathered data was done.

RESULTS

Clinical leaders in nursing homes can be defined as passionate healthcare professionals providing person-centred care with strong communication skills. They are clinical experts in their field and motivated to engage in lifelong learning. They are team players with informal leadership skills. They are visionary, committed, resilient and responsive. Awareness of the definition and the main characteristics of clinical leadership is necessary to facilitate the identification, support and development of healthcare professionals. Focussing on the development of competencies, training courses and monitoring and assessment methods is necessary to improve the evidence of clinical leadership in nursing homes.

The Need for Competency-Based Education

OBJECTIVES

While pharmacy education updates learning as new information arises, changes to learning experiences can trail behind current practices and technology. There have been multiple calls for radical changes in how health professions education is delivered to ensure patients are receiving high-quality care. Competency-based education has been one way discussed in the literature for how to handle this need to develop students who have a willingness to learn and can problem-solve. The goal of this review is to examine whether competency-based education is needed to drive the profession of pharmacy forward.

FINDINGS

To address, we collaboratively identified stakeholder perspectives to evaluate the need. The following stakeholders achieved consensus among the committee members: patients/society, learners, workplace/profession, and academic institutions.

SUMMARY

Based on those perspectives, needs, and gaps to address those needs were identified and are presented in this review.

Developing a competency model for Chinese general practitioners: a mixed-methods study

BACKGROUND

The Chinese government has formulated a series of policies and strengthened training of general practitioners (GPs) to support their role as "gatekeepers" of residents' health. This study aimed to explore the core competencies of Chinese GPs and develop a competency framework in line with China's actual conditions, which can provide a more scientific basis for the education, training, and evaluation of GPs.

METHODS

Literature analysis and behaviour event interviews were conducted to build the competency dictionary and the initial version of the competency model. Two rounds of Delphi were performed to gain consensus on the final model. The questionnaire survey was carried out in 10 provinces (municipalities, autonomous regions) of China, and GPs were invited to score the importance of each competency item. The total sample was randomly divided into two groups. One group was for exploratory factor analysis (EFA), and the other was for confirmatory factor analysis (CFA) to examine the scale's reliability and validity.

RESULTS

The dictionary of general practitioners' competency including 107 competency items was constructed. After two rounds of Delphi, a consensus was reached on 60 competencies in 6 domains. A total of 1917 valid questionnaires were obtained in the nationwide survey. The average importance score of all second-level indicators is 4.53 ± 0.45. The Cronbach's α coefficient is 0.984. The results of the five factors extracted by EFA showing the 68.16% cumulative explained variance variation is considered to be consistent with the six dimensions obtained by Delphi after thorough discussion. The model fitness indexes obtained by CFA were acceptable (χ2/df = 4.909, CFI = 0.869, NFI = 0.841, RMSEA = 0.065). The values of the composite reliability (CR) of the six dimensions were all greater than 0.7 (0.943, 0.927, 0.937, 0.927, 0.943, 0.950), and the average of variance extracted (AVE) were all greater than 0.5 (0.562, 0.613, 0.649, 0.563, 0.626, 0.635). The results showed that the model has good reliability and validity.

CONCLUSION

A competency model for GPs suited to China has been developed, which may offer guidance for future training and medical licensing examinations of GPs.

Development and Pilot Testing of a Programmatic System for Competency Assessment in US Anesthesiology Residency Training

BACKGROUND

In 2018, a set of entrustable professional activities (EPAs) and procedural skills assessments were developed for anesthesiology training, but they did not assess all the Accreditation Council for Graduate Medical Education (ACGME) milestones. The aims of this study were to (1) remap the 2018 EPA and procedural skills assessments to the revised ACGME Anesthesiology Milestones 2.0, (2) develop new assessments that combined with the original assessments to create a system of assessment that addresses all level 1 to 4 milestones, and (3) provide evidence for the validity of the assessments.

METHODS

Using a modified Delphi process, a panel of anesthesiology education experts remapped the original assessments developed in 2018 to the Anesthesiology Milestones 2.0 and developed new assessments to create a system that assessed all level 1 through 4 milestones. Following a 24-month pilot at 7 institutions, the number of EPA and procedural skill assessments and mean scores were computed at the end of the academic year. Milestone achievement and subcompetency data for assessments from a single institution were compared to scores assigned by the institution's clinical competency committee (CCC).

RESULTS

New assessment development, 2 months of testing and feedback, and revisions resulted in 5 new EPAs, 11 nontechnical skills assessments (NTSAs), and 6 objective structured clinical examinations (OSCEs). Combined with the original 20 EPAs and procedural skills assessments, the new system of assessment addresses 99% of level 1 to 4 Anesthesiology Milestones 2.0. During the 24-month pilot, aggregate mean EPA and procedural skill scores significantly increased with year in training. System subcompetency scores correlated significantly with 15 of 23 (65.2%) corresponding CCC scores at a single institution, but 8 correlations (36.4%) were <30.0, illustrating poor correlation.

CONCLUSIONS

A panel of experts developed a set of EPAs, procedural skill assessment, NTSAs, and OSCEs to form a programmatic system of assessment for anesthesiology residency training in the United States. The method used to develop and pilot test the assessments, the progression of assessment scores with time in training, and the correlation of assessment scores with CCC scoring of milestone achievement provide evidence for the validity of the assessments.

A Journey of Innovation: 40 years of Pioneering Medical Education at the Aga Khan University Medical College in Karachi, Pakistan

This article presents an overview of Aga Khan University's (AKU) pioneering medical education initiatives over the past 40 years, exploring its impact on healthcare in the region and its commitment to advancing medical education and research in the developing world. Established in 1983 as the first private university in Pakistan, AKU has evolved into a global institution with a focus on improving healthcare standards and addressing healthcare needs in the developing world. The article also discusses the undergraduate and postgraduate medical education programs at AKU Medical College, Pakistan, highlighting their unique features and pioneering approaches to medical education. The institution's journey highlights its ability to adapt to the evolving healthcare landscape while maintaining a focus on quality and excellence, offering a model for other institutions striving to meet healthcare needs in low- and middle-income countries.

Enabling Factors for the Implementation of Competency-Based Curricula in Colleges and Schools of Pharmacy

OBJECTIVES

To review the implementation drivers of competency-based pharmacy education (CBPE) and provide recommendations for enablers.

FINDINGS

Competency-based education is an emerging model in the health professions, focusing on time-variable competency development and achievement compared with a time-bound, course-based, traditional model. CBPE is an outcomes-based organized framework of competencies enabling pharmacists to meet health care and societal needs. However, challenges need to be recognized and overcome for the successful implementation of CBPE. Competency drivers include defining the competencies and roles of stakeholders, developing transparent learning trajectories and aligned assessments, and establishing lifetime development programs for stakeholders. Organization drivers include developing support systems for stakeholders; facilitating connections between all educational experiences; and having transparent assessment plans, policies, and procedures that align with core CBPE precepts, including the sustainability of time-variability. Leadership drivers include establishing growth mindset and facilitating a culture of connection between workplace and educational environments, program advocacy by institutional leaders, accepting failures as part of the process, shifting the organizational culture away from learner differentiation toward competence, and maintaining sufficient administrative capability to support CBPE.

SUMMARY

The successful implementation of CBPE involves enabling the competency, organization, and leadership drivers that will lead to program success. More research is needed in the areas of creation, implementation, and assessment of CBPE to determine success in this model. We have reviewed and provided recommendations to enable the drivers of successful implementation of CBPE.

Competency-Based Time-Variable Anesthesiology Residency Training: Identification of Problems and Solutions

BACKGROUND

Global medical education is gradually moving toward more comprehensive implementations of a competency-based education (CBE) model. Elimination of standard time-based training and adoption of time-variable training (competency-based time-variable training [CB-TVT]) is one of the final stages of implementation of CBE. While CB-TVT has been implemented in some programs outside the United States, residency programs in the United States are still exploring this approach to training. The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) are encouraging member boards and residency review committees to consider innovative ways programs could implement CB-TVT. The goals of this study were to (1) identify potential problems with the implementation of CB-TVT in anesthesiology residency training, (2) rank the importance of the problems and the perceived difficulty of solving them, and (3) develop proposed solutions to the identified problems.

METHODS

Study participants were recruited from key stakeholder groups in anesthesiology education, including current or former program directors, department chairs, residents, fellows, American Board of Anesthesiology (ABA) board members, ACGME residency review committee members or ACGME leaders, designated institutional officials, residency program coordinators, clinical operations directors, and leaders of large anesthesiology community practice groups. This study was conducted in 2 phases. In phase 1, survey questionnaires were iteratively distributed to participants to identify problems with the implementation of CB-TVT. Participants were also asked to rank the perceived importance and difficulty of each problem and to identify relevant stakeholder groups that would be responsible for solving each problem. In phase 2, surveys focused on identifying potential solutions for problems identified in phase 1.

RESULTS

A total of 36 stakeholders identified 39 potential problems, grouped into 7 major categories, with the implementation of CB-TVT in anesthesiology residency training. Of the 39 problems, 19 (48.7%) were marked as important or very important on a 5-point scale and 12 of 19 (63.2%) of the important problems were marked as difficult or very difficult to solve on a 5-point scale. Stakeholders proposed 165 total solutions to the identified problems.

CONCLUSIONS

CB-TVT is a promising educational model for anesthesiology residency, which potentially results in learner flexibility, individualization of curricula, and utilization of competencies to determine learner advancement. Because of the potential problems with the implementation of CB-TVT, it is important for future pilot implementations of CB-TVT to document realized problems, efficacy of solutions, and effects on educational outcomes to justify the burden of implementing CB-TVT.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The 2022 European postgraduate (residency) programme in neurology in a historical and international perspective

BACKGROUND AND PURPOSE

Neurology residency programmes, which were first established at the beginning of the 20th century, have become mandatory all over Europe in the last 40-50 years. The first European Training Requirements in Neurology (ETRN) were published in 2005 and first updated in 2016. This paper reports the most recent revisions of the ETRN.

METHODS

Members of the EAN board performed an in depth revision of the ETNR 2016-version, which was reviewed by members of the European Board and Section of Neurology of the UEMS, the Education and Scientific Panels, the Resident and Research Fellow Section and the Board of the EAN, as well as the presidents of the 47 European National Societies.

RESULTS

The new (2022) ETRN suggest a 5-year training subdivided in three phases: a first phase (2 years) of general neurology training, a second phase (2 years) of training in neurophysiology/neurological subspecialties and a third phase (1 year) to expand clinical training (e.g., in other neurodisciplines) or for research (path for clinical neuroscientist). The necessary theoretical and clinical competences as well as learning objectives in diagnostic tests have been updated, are newly organized in four levels and include 19 neurological subspecialties. Finally, the new ETRN require, in addition to a programme director, a team of clinician-educators who regularly review the resident's progress. The 2022 update of the ETRN reflects emerging requirements for the practice of neurology and contributes to the international standardization of training necessary for the increasing needs of residents and specialists across Europe.

Lessons From Organic Chemistry: The Case for Considering Both High Standards and Equity in Assessment

ABSTRACT

In this commentary, the authors explore the tension of balancing high performance standards in medical education with the acceptability of those standards to stakeholders (e.g., learners and patients). The authors then offer a lens through which this tension might be considered and ways forward that focus on both patient outcomes and learner needs.In examining this phenomenon, the authors argue that high performance standards are often necessary. Societal accountability is key to medical education, with the public demanding that training programs prepare physicians to provide high-quality care. Medical schools and residency programs, therefore, require rigorous standards to ensure graduates are ready to care for patients. At the same time, learners' experience is important to consider. Making sure that performance standards are acceptable to stakeholders supports the validity of assessment decisions.Equity should also be central to program evaluation and validity arguments when considering performance standards. Currently, learners across the continuum are variably prepared for the next phase in training and often face inequities in resource availability to meet high passing standards, which may lead to learner attrition. Many students who face these inequities come from underrepresented or disadvantaged backgrounds and are essential to ensuring a diverse medical workforce to meet the needs of patients and society. When these students struggle, it contributes to the leaky pipeline of more socioeconomically and racially diverse applicants.The authors posit that 4 key factors can balance the tension between high performance standards and stakeholder acceptability: standards that are acceptable and defensible, progression that is time variable, requisite support structures that are uniquely tailored for each learner, and assessment systems that are equitably designed.

A National Survey Exploring Practices and Perceptions of Sharing Experiential Evaluations With Future Preceptors

OBJECTIVE

This study aimed to understand pharmacy programs' policies and processes of sharing Advanced Pharmacy Practice Experience (APPE) assessment information among preceptors and to determine the types of grading scales currently being used nationally.

METHODS

A 14-question survey was utilized to collect information on Experiential Education policies and practices regarding APPE evaluations and assessment data sharing. The survey was administered electronically to Experiential Education Administrators at accredited schools of pharmacy nationally and gathered information on approach to APPE assessment, information sharing with future preceptors and open-ended responses on how struggling student learners are supported. Descriptive statistics were used to analyze quantitative responses, while qualitative open-ended comments were analyzed using thematic analysis.

RESULTS

A total of 95 responses were included in the analysis (67.9% response rate). The majority of programs (83.2%) reported not sharing student performance assessments with future preceptors. Themes that emerged from the analysis of open-ended comments included concerns about bias and privacy violations, and the benefits of sharing evaluations for preceptor preparation and longitudinal student growth. The grading approach varied, with 53.7% of programs using traditional tiered letter grades and 45.3% using a pass/fail grading system.

CONCLUSION

Most pharmacy programs do not share APPE assessment information with future preceptors due to concerns about bias and protecting student privacy. However, programs may be looking for alternative processes that address the need to facilitate student growth and to support struggling learners. Examples shared may provide stimulus and insight for Experiential Education Offices to engage in programmatic discussions about the approach to assessment sharing practices.

Competency-based pharmacy education definition: What components need to be defined to implement it?

OBJECTIVES

This study aimed to define the essential elements in the proposed competency-based pharmacy education (CBPE) definition, provide the key defining components of each essential element on the basis of educational theory and evidence, and define how the essential elements meet the identified needs for CBPE.

METHODS

best-practice integrative review was conducted as part of the work of the American Association of Colleges of Pharmacy CBPE Task Force to define the essential elements in the CBPE definition and how these elements fit with the need for CBPE. The definition was compared with other published competency-based education definitions across K-12, higher education, medical education, and veterinary education. Task Force members then met to develop a consensus on the core components of the 5 essential elements in the definition. Next, the Task Force evaluated the fit of CBPE by matching the identified needs, discussed in detail elsewhere, across each of the stakeholder perspectives with the core components of the 5 essential elements in the derived definition of CBPE.

FINDINGS

Upon review of the proposed CBPE definition, the Task Force identified 5 essential elements. These elements include the following: meeting health care and societal needs, outcomes-based curricular model, de-emphasized time, learner-centered culture, and authentic teaching and learning strategies aligned to assessments.

SUMMARY

This article helps to establish a common language for CBPE by defining the essential elements of the core components of the definition, and provides a starting point for further exploration of CBPE.

A Model Curriculum For New Faculty Coaches in Undergraduate Medical Education

OBJECTIVES

Coaching is an interactive process of performance improvement accomplished by fostering a coachee's ability to critically self-evaluate, create goals, and develop a plan for action. It is being increasingly used in medical education, both at the undergraduate and graduate levels. The American Medical Association (AMA) recommends robust faculty development for any coaching program. Our institution created a mandatory coaching program for students starting in August 2022 with 22 faculty coaches.

METHODS

We used Kern's 6-step model for curriculum development to create our institution's faculty development for coaches. This manuscript describes the process of development, implementation, and early program evaluation for the curriculum for faculty coaches for the first 4 months of our mandatory coaching program. The objectives and teaching strategies are outlined. Our program evaluation consisted of immediate and follow-up surveys of faculty attendees.

RESULTS

Content in the faculty development program describing the medical student curriculum, assessment, and student resources improved faculty perceived knowledge and confidence. Specific training in coaching skills, including a simulation using standardized students was used and found to be essential. We offer lessons learned from our coaches regarding timing and content for any faculty development curriculum for new coaches.

CONCLUSIONS

Considerations for future faculty development curricula for academic coaching programs include timing of the faculty development, content consideration after three coaching sessions, and potential content additions and deletions. The curriculum outlined can be taken and immediately adapted for any school of medicine embarking on a coaching program for students.

Longitudinality Matters: Qualitative Perspectives on a Longitudinal Clinical Experience in a Psychiatry Residency Training Program

OBJECTIVE

Longitudinal models of clinical care and education can positively impact the patient and provider experience in terms of health outcomes, satisfaction, and motivation. While residency programs have seen an increase in primary care longitudinal clinical experiences (LCEs), defined as outpatient clinics in which patients are seen by residents over the course of their entire training, less is known about such opportunities in psychiatry residency programs. This qualitative study explores the impact of a longitudinal training model on psychiatric resident skill development, relationships in the clinical learning environment, and professional identity formation.

METHODS

The authors conducted 24 semi-structured interviews of residents, graduates, and faculty in three well-established LCE clinics in a single, multi-site, academic psychiatry residency program. Transcripts were analyzed using inductive thematic analysis techniques.

RESULTS

Themes were categorized into benefits and challenges. For benefits, themes included longitudinal relationships, improved feedback, near-peer teaching, early outpatient exposure, graduated independence, skill development, patient population expertise, and solidification of professional identity. For challenges, themes included system logistics, offsite panel management, and intermittent presence of junior trainees.

CONCLUSION

Results suggest that overall, residents and faculty find the LCE a positive learning opportunity that has contributed to their professional development. LCEs do appear to have distinct challenges, largely logistical in nature, which can interfere with the favorability of residents' experiences. Developing strategies up front to minimize these logistical challenges will support the success of a longitudinal program.

The development and validation of a global advanced development framework for the pharmacy workforce: a four-stage multi-methods approach

BACKGROUND

Studies have indicated that a generalisable and translatable global framework is a useful tool for supporting career progression and recognising advanced practice.

AIM

To develop and validate a global advanced competency development framework as a tool to advance the pharmacy profession globally.

METHOD

A four-stage multi-methods approach was adopted. In sequence, this comprised an assessment of initial content and a cultural validation of the advanced level framework. Following this, we conducted a transnational modified Delphi followed by an online survey sampling the global pharmacy leadership community. Finally, a series of case studies was constructed exemplifying the framework implementation.

RESULTS

Initial validation resulted in a modified draft competency framework comprising 34 developmental competencies across six clusters. Each competency has three phases of advancement to support practitioner progression. The modified Delphi stage provided feedback on framework modifications related to cultural issues, including missing competencies and framework comprehensiveness. External engagement and case study stages provided further validity on the framework implementation and dissemination.

CONCLUSION

The four-staged approach demonstrated transnational validation of a global advanced competency framework as a mapping and development tool for the pharmacy professions. Further study is needed to develop a global glossary of terminologies on advanced and specialist practice. Also, developing an accompanying professional recognition system and education and training programmes to support framework implementation is recommended.

Residents as Medical Coaches

OBJECTIVES

With the recent implementation of Competency-based Medical Education (CBME) and emphasis on direct observation of learners, there is an increased interest in the concept of clinical coaching. While there is considerable literature on the role of attending physicians as coaches, little data is available on the role of residents as coaches, and residents' perceptions about effective coaching. We aimed to identify distinct characteristics of residents' coaching, to examine residents' perceptions on what they valued most in clinical coaches, and to explore trainees' ideas about how to optimize this role.

DESIGN

We performed an exploratory qualitative study, using 45 minutes semi-structured interviews. We did a thematic analysis of the interview transcripts using both inductive and deductive coding.

PARTICIPANTS

We invited and interviewed 5 surgical and 5 nonsurgical residents, and 3 surgical and 3 nonsurgical attending staff. Residents were recruited from all post graduate levels and from a variety of programs.

SETTING

Our study was done in a large tertiary teaching hospital.

RESULTS

Residents perceived that they have a significant role as coaches for junior learners, different from the attending's role. The proximity between the coach and the coaches leads to a different supervisor-learner rapport. This was of benefit as learners described feeling more comfortable making mistakes and seeking feedback, which potentiates effective coaching. Residents reported feeling that it was easier to coach their recently-acquired skills as the subtleties of the tasks and the troubleshooting were fresher in memory. Residents expressed appreciating a coach who values autonomy and does not intervene except when patient safety is at risk. Strategies identified to further optimize residents' role as coaches include placing coaching as a priority, ensuring dedicated time, and offering teaching sessions on coaching.

CONCLUSIONS

Residents have distinct roles as coaches, driven by their recent experience being coached and as near peers. More research is needed to evaluate concrete measures to optimize residents' role as coaches and to improve their coaching skills.

Bias in Surgical Residency Evaluations: A Scoping Review

OBJECTIVE

Given widespread disparities in the surgical workforce and the advent of competency-based training models that rely on objective evaluations of resident performance, this review aims to describe the landscape of bias in the evaluation methods of residents in surgical training programs in the United States.

DESIGN

A scoping review was conducted within PubMed, Embase, Web of Science, and ERIC in May 2022, without a date restriction. Studies were screened and reviewed in duplicate by 3 reviewers. Data were described descriptively.

SETTING/PARTICIPANTS

English-language studies conducted in the United States that assessed bias in the evaluation of surgical residents were included.

RESULTS

The search yielded 1641 studies, of which 53 met inclusion criteria. Of the included studies, 26 (49.1%) were retrospective cohort studies, 25 (47.2%) were cross-sectional studies, and 2 (3.8%) were prospective cohort studies. The majority included general surgery residents (n = 30, 56.6%) and nonstandardized examination modalities (n = 38, 71.7%), such as video-based skills evaluations (n = 5, 13.2%). The most common performance metric evaluated was operative skill (n = 22, 41.5%). Overall, the majority of studies demonstrated bias (n = 38, 73.6%) and most investigated gender bias (n = 46, 86.8%). Most studies reported disadvantages for female trainees regarding standardized examinations (80.0%), self-evaluations (73.7%), and program-level evaluations (71.4%). Four studies (7.6%) assessed racial bias, of which all reported disadvantages for trainees underrepresented in surgery.

CONCLUSIONS

Evaluation methods for surgery residents may be prone to bias, particularly with regard to female trainees. Research is warranted regarding other implicit and explicit biases, such as racial bias, as well as for nongeneral surgery subspecialties.

Precision Medical Education

Medical schools and residency programs are increasingly incorporating personalization of content, pathways, and assessments to align with a competency-based model. Yet, such efforts face challenges involving large amounts of data, sometimes struggling to deliver insights in a timely fashion for trainees, coaches, and programs. In this article, the authors argue that the emerging paradigm of precision medical education (PME) may ameliorate some of these challenges. However, PME lacks a widely accepted definition and a shared model of guiding principles and capacities, limiting widespread adoption. The authors propose defining PME as a systematic approach that integrates longitudinal data and analytics to drive precise educational interventions that address each individual learner's needs and goals in a continuous, timely, and cyclical fashion, ultimately improving meaningful educational, clinical, or system outcomes. Borrowing from precision medicine, they offer an adapted shared framework. In the P4 medical education framework, PME should (1) take a proactive approach to acquiring and using trainee data; (2) generate timely personalized insights through precision analytics (including artificial intelligence and decision-support tools); (3) design precision educational interventions (learning, assessment, coaching, pathways) in a participatory fashion, with trainees at the center as co-producers; and (4) ensure interventions are predictive of meaningful educational, professional, or clinical outcomes. Implementing PME will require new foundational capacities: flexible educational pathways and programs responsive to PME-guided dynamic and competency-based progression; comprehensive longitudinal data on trainees linked to educational and clinical outcomes; shared development of requisite technologies and analytics to effect educational decision-making; and a culture that embraces a precision approach, with research to gather validity evidence for this approach and development efforts targeting new skills needed by learners, coaches, and educational leaders. Anticipating pitfalls in the use of this approach will be important, as will ensuring it deepens, rather than replaces, the interaction of trainees and their coaches.

How Does TIMELESS Training Impact Resident Motivation for Learning, Assessment, and Feedback? Evaluating a Competency-Based Time-Variable Training Pilot

PURPOSE

As competency-based medical education has become the predominant graduate medical education training model, interest in time-variable training has grown. Despite multiple competency-based time-variable training (CBTVT) pilots ongoing in the United States, little is known about how this training approach impacts learners. The authors aim to explore how their CBTVT pilot program impacted resident motivation for learning, assessment, and feedback.

METHOD

The authors performed a qualitative educational case study on the Transitioning in Internal Medicine Education Leveraging Entrustment Scores Synthesis (TIMELESS) program at the University of Cincinnati from October 2020 through March 2022. Semistructured interviews were conducted with TIMELESS residents (n = 9) approximately every 6 months to capture experiences over time. The authors used inductive thematic analysis to develop themes and compared their findings with existing theories of learner motivation.

RESULTS

The authors developed 2 themes: TIMELESS had variable effects on residents' motivation for learning and TIMELESS increased resident engagement with and awareness of the program of assessment. Participants reported increased motivation to learn and seek assessment, though some felt a tension between performance (e.g., advancement through the residency program) and growth (e.g., improvement as a physician). Participants became more aware of the quality of assessments they received, in part due to TIMELESS increasing the perceived stakes of assessment, and reported being more deliberate when assessing other residents.

CONCLUSIONS

Resident motivation for learning, assessment, and feedback was impacted in ways that the authors contextualize using current theories of learner motivation (i.e., goal orientation theory and attribution theory). Future research should investigate how interventions, such as coaching, guided learner reflection, or various CBTVT implementation strategies, can help keep learners oriented toward mastery learning rather than toward performance.

Opportunities and Challenges for Implementation of Harmonized Competence-Based Curricula in Medicine and Nursing Programmes in Tanzania: Experiences of Biomedical Sciences' Stakeholders

Background

In 2012, the Muhimbili University of Health and Allied Sciences (MUHAS) embarked on structured competency-based curricula (CBC) for its programmes. Other health profession training institutions continued with their traditional way of teaching and thus causing variability in the competencies of the graduates. We aimed to analyze the experiences of different stakeholders on the implementation of CBC specifically on biomedical sciences by MUHAS to inform the development of harmonized competency-based curricula in three health professional training institutions in Tanzania.

Methods

We adopted an exploratory case study to analyse the implementation of CBC in programmes of Medicine and Nursing involving MUHAS graduates, immediate supervisors at the employment sites, faculty, and continuing students at MUHAS. Kiswahili guides were used to conduct the in-depth interviews (IDIs) and focus group discussions (FGDs). Qualitative content analysis was adopted for analysis.

Results

From the 38 IDIs and 15 FGDs, four categories of human resources teaching and learning environment; curriculum content; and support systems emerged. Human resources were attributed to the shortage of an adequate number of faculty and teaching skills variation. The curriculum content category was linked to the redundancy of courses or topics, poor sequencing of some topics or courses, and limited time for teaching some essential courses or topics. Training and practice area mismatch, accommodation to students, teaching space, and library were the sub-categories linked to teaching and learning environment. Lastly, support systems related to teaching methods and opportunities for improving teaching and learning were revealed.

Conclusion

The findings of this study highlight the challenges and opportunities for the implementation of CBC. The solutions to the revealed challenges are beyond the training institutions' capacity. The latter call for multi-stakeholder engagement including those from the public and private sectors in health, higher education and finance for common and sustainable solutions.

Investigating feedback orientation in medical learners

BACKGROUND/PURPOSE

Feedback processes in health professions education (HPE) are not always successful. While recommendations to improve feedback provision dominate the literature, studying specific learner attributes that impact feedback uptake may also improve feedback processes. Feedback orientation is a concept from management science involving four dimensions of learner attributes and attitudes that impact their feedback uptake: utility, accountability, social awareness, and feedback self-efficacy. Feedback orientation may represent a valuable concept in HPE. We aimed to understand medical learners' feedback orientation at different stages in their development.

METHODS

We used the Feedback Orientation Scale, a 20-item survey instrument, for a cross-sectional analysis of feedback orientation in medical students and Internal Medicine residents at one large academic center. We performed descriptive statistics and analysis of variance for data analysis.

RESULTS

We found the same factors (dimensions) to feedback orientation in our population as in management science. Overall feedback orientation scores were high and were largely consistent across trainee levels. Utility was the domain that was highest across learners, whereas feedback self-efficacy was lowest.

CONCLUSIONS

Feedback orientation represents a useful concept to explore medical learners' attitudes toward feedback's role in their development. The four domains can help guide further nuanced feedback research and application.[Box: see text].

Which Entrustment-Supervision Scale is Right for Pharmacy Education?

Entrustable professional activities (EPAs) are an outgrowth of the competency-based educational model to support workplace-based learner assessments and evaluation. A learner's performance of EPAs is assessed by the degree of provided entrustment and required supervision rather than by a score, percentage, or letter grade typically assigned in traditional academic coursework. Entrustment-supervision (ES) scales are used to document learner progression and steer learner development over time. The purpose of this article is to critique various ES tools in health professions education for utilization within an EPA framework for learner assessment in workplace-based settings and to determine which will best suit pharmacy education. Exploring the advantages and disadvantages across all types of ES scales is a critical step in determining the most useful ES tool for use within a specific pharmacy institution and across the Academy. An ES scale with the traditional 5 levels, a prospective assessment frame, and increased stratification at lower levels should be recommended by the Academy and utilized in workplace-based settings for formative and summative assessment to provide more valid assessment of learners, support the ideal of life-long learning, and give more meaning for pharmacy faculty and learners within assessment.

Barriers to Accessing Mental Health Support Services in Undergraduate Medical Training: A Multicenter, Qualitative Study

PURPOSE

Medical students report higher levels of burnout, anxiety, and depression compared with age-matched peers. These mental health challenges have been linked to reduced workplace productivity, empathy, and professionalism. Yet, students experiencing mental health issues often decide not to access mental health resources, citing limited time and concerns about confidentiality, stigma, and the cost of private therapy. This study aimed to provide a framework for understanding barriers medical students face regarding access to mental health resources.

METHOD

A constructivist grounded theory approach was employed, with 24 students from 6 medical schools in Ontario, Canada, participating in semistructured telephone interviews between May 2019 and February 2020. Participants were purposively sampled to capture a broad range of experiences, institutional contexts, and training levels. The authors then developed a framework to conceptualize the barriers that medical students face while accessing mental health resources.

RESULTS

The information obtained from the interviews revealed that the barriers were both overt and covert. Overt barriers were primarily administrative challenges, including restrictive leave of absence policies and sick days, mandatory reporting of extended sick leave time during the residency selection process, time-restricted academic and clinical schedules, and difficulty in accessing mental health supports during distance education. Covert barriers to accessing mental health supports included a medical culture not conducive to mental health, felt stigma (i.e., fear of stigma and being labeled as weak), and the hidden curriculum (i.e., the unofficial or unintended rules and mannerisms propagated within medical education systems).

CONCLUSIONS

Better understanding the overt and covert barriers that medical students to face while accessing mental health supports may help guide and inspire new advocacy efforts to enhance medical student well-being.

Impact of Students' Scheduling Choice on Clerkship Examination Score Performance in a Time-Varying Competency-Based Curriculum

PURPOSE

Standardized end-of-clerkship examinations typically occur on the last day of the clerkship. However, recent trends toward time-varying competency-based medical education have offered students more test scheduling flexibility, creating an opportunity to study the impact of student-selected examination timing.

METHOD

Starting with the graduating class of 2018, students took the required standardized end-of-core clerkship examinations at any available time they chose during their clinical years. Before this change, these examinations were administered to all students on the last day of the clerkship. Students' examination dates relative to clerkship completion were analyzed between 2017 and 2020 (inclusive of before and after flexible exam timing) to assess the impact that student-selected exam timing had on test performance on National Board of Medical Examiners shelf clinical science examinations for required core clerkships.

RESULTS

Data on 146 medical students in 2017 (fixed exam timing) and 466 medical students between 2018 and 2020 (flexible exam timing) were included. Among students offered flexible exam timing, between 2.7% (internal medicine) and 14.6% (psychiatry) took their exam before actually taking clerkship, while between 22.7% (psychiatry) and 40.0% (surgery) took their exam more than 90 days after the clerkship ended. Exam scores were statistically higher for those who took the exam at a time of their choosing compared with those who were required to take it at the end of individual rotations and when the exam scores were combined (fixed exam timing mean = 73.9, standard deviation [SD] = 7.8; flexible exam timing mean = 77.4, SD = 6.0, P < .001). The percent of students with passing scores was statistically higher in internal medicine, pediatrics, and psychiatry.

CONCLUSIONS

Self-selection of shelf exam timing appears to increase shelf exam scores. As more medical schools transition to competency-based medical education, providing scheduling flexibility appears not to negatively affect student achievement.

Learning pediatric emergency medicine over time: A realist evaluation of a longitudinal pediatric emergency medicine clinical experience

Introduction

Emergency medicine (EM) practitioners must be proficient at caring for patients of all ages, including pediatric patients. Traditionally, EM trainees learn pediatric emergency medicine (PEM) through block rotations. This is problematic due to the seasonal nature of pediatric diseases and infrequent critical events. Spaced repetition learning theory suggests PEM would be better learned through longitudinal rotations. The transition to competency-based medical education (CBME) in Canada is accelerating the need to find novel ways to attain competencies in postgraduate training. At McMaster University, senior EM trainees can choose either traditional PEM blocks or longitudinal rotations. Our objective was to understand how learners experience these different rotations given the transition to CBME in Canada.

Methods

Using a realist framework of program evaluation, we conducted semistructured interviews with key stakeholders (trainees, program directors, attending physicians) in EM. The realist framework was used to understand how context interacts with theoretical mechanisms to produce outcomes of interest. Data were analyzed using inductive, conventional content analysis. All investigators coded a subset of transcripts independently and in duplicate to achieve intercoder agreement.

Results

A total of 13 interviews were completed with trainees (n = 11) and staff physicians (n = 2). The learning experience exists within an educational and clinical context, which are logistically distinct but inseparable. The longitudinal learning experience appears to improve learning through spaced repetition, which prevents atrophy of skills and knowledge while also benefitting from the offsetting of seasonal variability associated with many pediatric diseases. Improved feedback and entrustment are facilitated through the building of coaching relationships over time. Barriers to the learning experience are related mainly to logistical difficulties associated with resolving longitudinal and blocked learning experiences. Improved relationships with the interprofessional team may provide distinct learning opportunities and improved team functioning. Block rotations were identified as more valuable to junior trainees learning fundamental concepts.

Conclusions

Longitudinal learning provides numerous advantages to learning PEM, including increased case variety, spaced repetition of core concepts, and a perception of greater entrustment of the learner through formation of coaching relationships over time. Future projects looking to quantify the differences between longitudinal and block learning to objectively show a difference in skills and knowledge are needed.

Implementing competency-based medical education in post-graduate ophthalmology training: Understanding key concepts and methodologies and overcoming challenges

The National Medical Council (NMC) has mandated that all post-graduate training shall be competency-based, following the principles of Competency. Based Medical Education (CBME). This aims to serve the dual purpose of standardizing ophthalmology post-graduate training and to overcome the shortcomings of the traditional curriculum by employing innovative and interactive teaching-learning and assessment techniques to produce competent ophthalmologists well equipped with clinical, surgical, and professional skills relevant to current times. CBME marks a paradigm shift from traditional curriculum methodologies and involves the introduction of several new concepts. This article aims to highlight the key principles of CBME and the various teaching-learning and assessment technique methodologies which can be employed for post-graduate training. It also highlights the various challenges that are likely to be faced in its implementation and measures to overcome them.

Crises as the Crucible for Change in Physical Therapist Education

This Perspective issues a challenge to physical therapists to reorient physical therapist education in ways that directly address the crises of COVID-19 and systemic racism. We advocate that professional education obligates us to embrace the role of trusteeship that demands working to meet society's needs by producing graduates who accept their social and moral responsibilities as agents and advocates who act to improve health and health care. To achieve this, we must adopt a curriculum philosophy of social reconstruction and think more deeply about the why and how of learning. Currently, health professions education places strong emphasis on habits of head (cognitive knowledge) and hand (clinical skills) and less focus on habits of heart (professional formation). We believe that habits of heart are the essential foundations of the humanistic practice needed to address health inequities, find the moral courage to change the status quo, and address imbalances of power, privilege, and access. A social reconstruction orientation in physical therapist education not only places habits of heart at the center of curricula, but it also requires intentional planning to create pathways into the profession for individuals from underrepresented groups. Adopting social reconstructionism begins with a faculty paradigm shift emphasizing the learning sciences, facilitating learning, metacognition, and development of a lifelong master adaptive learner. Achieving this vision depends not only on our ability to meet the physical therapy needs of persons with COVID-19 and its sequalae but also on our collective courage to address injustice and systemic racism. It is imperative that the physical therapy community find the moral courage to act quickly and boldly to transform DPT education in ways that enable graduates to address the social determinants of health and their systemic and structural causes that result in health disparities. To succeed in this transformation, we are inspired and strengthened by the example set by Geneva R. Johnson, who has never wavered in recognizing the power of physical therapy to meet the needs of society.

Core competencies for a biomedical laboratory scientist - a Delphi study

BACKGROUND

After completing university education, biomedical laboratory scientists work in clinical laboratories, in biomedical research laboratories, in biotech, and in pharmaceutical companies. Laboratory diagnostics have undergone rapid development over the recent years, with the pace showing no signs of abatement. This rapid development challenges the competence of the staff and will most certainly influence the education of future staff. This study aimed to examine what was considered the necessary competencies needed to pursue a career as a biomedical laboratory scientist.

METHODS

A modified Delphi technique was used, with the panel of experts expressing their views in a series of three questionnaire. Consensus was defined as the point which 75 % or more of the panel participants agreed that a particular competency was necessary.

RESULTS

The study highlights the perceived importance of mostly generic competencies that relate to quality, quality assurance, and accuracy, as well as different aspects of safety, respect, trustworthiness (towards patients/clients and colleagues), and communication skills. The results also stress the significance of self-awareness and professionality.

CONCLUSIONS

We identified important competencies for biomedical laboratory scientists. Together with complementary information from other sources, i.e., guidelines, laws, and scientific publications, the competencies identified can be used as learning outcomes in a competency-based education to provide students with all the competencies needed to work as professional biomedical laboratory scientists.

Competency-Based Education and Practice in Physical Therapy: It's Time to Act!

Competency-based education (CBE) is a concept, a philosophy, and an approach to educational design where learner progression occurs when competency is demonstrated. It assumes a set of standard defined performance outcomes for any level of professional practice-students, residents, or practicing physical therapists. Those outcomes are based on the health needs of society and guide the curricular design, implementation, and evaluation of health professions education programs. Lack of a CBE framework-with no required demonstration of competence throughout one's career-has the potential to lead to variation in physical therapists' skills and to unwarranted variation in practice, potentially hindering delivery of the highest quality of patient care. CBE requires a framework that includes a commonly understood language; standardized, defined performance outcomes at various stages of learner development; and a process to assess whether competence has been demonstrated. The purpose of this perspective article is to (1) highlight the need for a shared language, (2) provide an overview of CBE and the impetus for the change, (3) propose a shift toward CBE in physical therapy, and (4) discuss the need for the profession to adopt a mindset requiring purposeful practice across one's career to safely and most efficiently practice in a given area. Utilizing a CBE philosophy throughout one's career should ensure high-quality and safe patient care to all-patient care that can adapt to the changing scope of physical therapist practice as well as the health care needs of society. The physical therapy profession is at a point at which we must step up the transition to a competency-based system of physical therapist education.

We Have No Choice but to Transform: The Future of Medical Education After the COVID-19 Pandemic

Medical education exists to prepare the physician workforce that our nation needs, but the COVID-19 pandemic threatened to disrupt that mission. Likewise, the national increase in awareness of social justice gaps in our country pointed out significant gaps in health care, medicine, and our medical education ecosystem. Crises in all industries often present leaders with no choice but to transform-or to fail. In this perspective, the authors suggest that medical education is at such an inflection point and propose a transformational vision of the medical education ecosystem, followed by a 10-year, 10-point plan that focuses on building the workforce that will achieve that vision. Broad themes include adopting a national vision; enhancing medicine's role in social justice through broadened curricula and a focus on communities; establishing equity in learning and processes related to learning, including wellness in learners, as a baseline; and realizing the promise of competency-based, time-variable training. Ultimately, 2020 can be viewed as a strategic inflection point in medical education if those who lead and regulate it analyze and apply lessons learned from the pandemic and its associated syndemics.

Competency-Based Medical Education: Considering Its Past, Present, and a Post-COVID-19 Era

Advancement toward competency-based medical education (CBME) has been hindered by inertia and a myriad of implementation challenges, including those associated with assessment of competency, accreditation/regulation, and logistical considerations. The COVID-19 pandemic disrupted medical education at every level. Time-in-training sometimes was shortened or significantly altered and there were reductions in the number and variety of clinical exposures. These and other unanticipated changes to existing models highlighted the need to advance the core principles of CBME. This manuscript describes the impact of COVID-19 on the ongoing transition to CBME, including the effects on training, curricular, and assessment processes for medical school and graduate medical education programs. The authors outline consequences of the COVID-19 disruption on learner training and assessment of competency, such as conversion to virtual learning modalities in medical school, redeployment of residents within health systems, and early graduation of trainees based on achievement of competency. Finally, the authors reflect on what the COVID-19 pandemic taught them about realization of CBME as the medical education community looks forward to a postpandemic future.

Medical Students' Technology Use for Self-Directed Learning: Contributing and Constraining Factors

BACKGROUND

With medical education shifting towards competency-based models, medical students are expected to be self-directed lifelong learners. There is an urgent need to understand what technology students adopt for self-directed learning and what factors contributed to students' self-initiated technology use.

METHOD

This study took place in a midwestern university medical school, which implements a flipped classroom model where students are required to learn all the course materials independently before class. Twenty-six first- and second-year medical students participated in a semi-structured interview about their self-directed learning with technology, and contributing factors towards technology use. A qualitative description methodology using thematic analysis was used to identify key themes from the interview data.

RESULTS

Medical students reported using four types of technologies for learning video resources, self-assessment tools, management tools, and social media. Three key determinants of students' self-directed technology use were identified, including perceived usefulness, subjective norms, and educational compatibility.

CONCLUSIONS

By probing medical students' self-initiated technology use and its determinants, this study suggested that in a self-directed learning environment, medical students used a variety of third-party resources to facilitate learning and develop self-directed learning skills. This study also provided important practical implications to better support students' productive use of technologies for self-directed learning.

Item-Level Analysis of a Newly Developed Interactive Nutrition Specific Physical Exam Competency Tool (INSPECT) Using the Rasch Measurement Model

The Interactive Nutrition Specific Physical Exam Competency Tool (INSPECT) is a tool designed specifically to observe and measure registered dietitian nutritionists' (RDNs) nutrition-focused physical exam (NFPE) competence in authentic acute care settings. The initial INSPECT items were generated and tested for content and face validity using expert RDNs' input. The INSPECT was further examined for inter-rater, intra-rater, and internal consistency using clinical supervisor observations of RDNs performing NFPE on patients in real-life acute care settings. These previous studies showed the INSPECT to have excellent content validity, acceptable face validity, good inter-rater reliability, moderate to strong intra-rater reliability, and excellent internal consistency. In the current study, the Rasch measurement model was applied to examine the item-level properties of the INSPECT. Results confirm that the INSPECT measured a single construct. All items fit the established criteria for clinical observations of >0.5 and <1.7, had positive point measure correlations, met the Wright Unidimensionality Index criteria of ≥0.9, exhibited one latent construct with >40% variance explained by the Rasch dimension as well as a sub-dimension based on item difficulty from the principal component analysis of the first contrast Rasch residuals. Rasch rating scale analysis revealed that the rating scale and majority of the items (39/41) fit the Rasch model. Rasch item hierarchy analysis matched the a priori hypothesized hierarchy for the top-most and bottom-most items. Ceiling effects were seen for three items (hand hygiene, personal protective equipment, and patient position) and one item (handgrip using hand dynamometer) reached the floor effect. Rasch reliability assessment demonstrated high person reliability (0.86), high item reliability (0.96), and person separation of 3.56 ability levels. The principal component analysis of residuals revealed two factors based on item difficulty, one for micronutrient exam and another for macronutrient exam, initial steps, and bedside manner. The resulting two factors may likely be due to a sub-dimension of the latent NFPE trait. Overall, the INSPECT items were found to have good item-level psychometrics. Continued testing of the INSPECT with RDNs at different ability levels will help to determine cut-off scores ranging from novice to expert. Establishing cut-off scores for the INSPECT will further enhance the utility of the tool.

Inter-Rater and Intra-Rater Reliability of the INSPECT (Interactive Nutrition Specific Physical Exam Competency Tool) Measured in Multi-Site Acute Care Settings

Even as new medical modalities, diagnostics, and technologies are rapidly changing healthcare, providing patients with safe, high-quality care remains the central focus. To provide safe patient care, healthcare providers are obligated to demonstrate and maintain the necessary competence. As more healthcare disciplines move toward a competency-based education model, it is essential to extend the competence verification from the academic educational level to the patient’s bedside. The nutrition-focused physical exam (NFPE) is a competency recently adopted by registered dietitian nutritionists (RDNs) for assessing patients’ nutritional status. Being a newly acquired skill, validated tools are required to measure NFPE competence during routine clinical practice. The Interactive Nutrition Specific Physical Exam Competency Tool (INSPECT) is a new tool developed specifically to observe and measure RDNs’ NFPE competence in clinical settings. The INSPECT was designed and validated for content using expert RDNs’ input in the first and second phases of the study. This current study aimed to assess the reliability of the INSPECT through multi-site observations by clinical supervisors evaluating RDNs’ NFPE competency during patient assessment. The INSPECT exhibited good inter-rater reliability (ICC = 0.78 for the first assessment and ICC = 0.68 for the second assessment), moderate to strong intra-rater reliability for 37 of 41 items (Spearman rho = 0.54 to 1.0), and excellent internal consistency (Cronbach’s α = 0.86 for the first assessment and α = 0.92 for the second assessment). In total, 10 out of the 11 INSPECT subsets showed good to excellent internal consistency (α ranging from 0.70 to 0.98). The results demonstrate that the INSPECT is a reliable tool, is stable over time, and has good agreement and excellent consistency between raters. The INSPECT can be a valuable tool to measure, promote and maintain RDNs’ NFPE competence in authentic acute care settings.

Development of an Entrustment-Supervision Assessment Tool for Pharmacy Experiential Education Using Stakeholder Focus Groups

Objective To devise a pharmacy-specific, expanded entrustable professional activities (EPA) entrustment-supervision scale that would frame preceptor ratings in a prospective and retrospective manner for use in experiential learning settings.Methods A series of focus group sessions were conducted to solicit expert opinion on how to develop and refine two entrustment-supervision scales. Purposive sampling was used to identify experts from different professional groups (physicians, pharmacy experiential administrators, and pharmacy practice faculty) who had extensive knowledge regarding EPAs and at least one publication related to EPAs. Panelists were invited to participate via email. Three focus sessions were conducted via videoconferencing between June and September 2019. The primary outcome was development of a pharmacy-specific EPA entrustment-supervision assessment tool. Secondary outcomes were individual entrustment-supervision statements across five levels of the entrustment-supervision scale.Results The focus group consisted of four pharmacy practice faculty, two experiential administrators, and one academic physician. Four concepts emerged from the focus group discussion: need for more granularity in entrustment-supervision scales; limitations due to differences in licensure requirements across the United States; present and ongoing use of expanded scales by schools and colleges of pharmacy; and uncertainty regarding how to rate entrustment-supervision when a student exhibits unprofessional behavior.Conclusion A pharmacy-specific, expanded EPA entrustment-supervision scale will be useful to support longitudinal assessment of learners in experiential settings where an EPA framework is utilized. Determining when to use a prospective versus retrospective perspective requires further evaluation.

Crossing the Innovation Chasm: Identifying Facilitators and Barriers to Early Adoption of the Global Health Starter Kit Curriculum

Purpose:

The Global Health Starter Kit (GHSK) is an interdisciplinary, competency-based, open access global health curriculum covering global disease and demographic trends, Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs), the connection between oral health and overall health, social determinants of health, and concepts of sustainable and ethical global health programs. In this study, we evaluate and describe barriers to and facilitators for using and implementing the GHSK curriculum across a variety of new users.

Methods:

This two-phase study uses the Roger’s Adoption Curve concept to standardize this evaluation and inform a strategic plan for continuing to move the curriculum across the chasm from early adopters to an early majority of global oral health educators and learners. We utilized a theoretical adoption framework to identify facilitators and barriers under the domains of innovation and curricular, educator and learner, and institutional and structural factors. Under qualitative Phase 1, five early adopter institutions were interviewed to elicit understanding of factors that contribute to adoption of the GHSK curriculum. Common themes identified were next used to create a Phase 2 quantitative survey for early majority subscribers of the GHSK (N = 27).

Results:

These qualitative and quantitative results showed an overall high satisfaction with the quality of the GHSK materials, but also effectively identified barriers to its adoption, including inexperience of faculty in teaching global oral health, a lack of awareness and marketing, and absence of global health accrediting requirements.

Conclusions:

By identifying the barriers and facilitators of GHSK curriculum integration, this study provides concrete and specific opportunities to improve its format, relevance, content, and delivery. This study outlines next steps to creating a standardized approach to successfully adopting competency-based global oral health teaching and learning.

Effectiveness of individual feedback and coaching on shared decision-making consultations in oncology care: Study protocol for a randomized clinical trial (Preprint)

Background

Shared decision-making (SDM) is particularly important in oncology as many treatments involve serious side effects, and treatment decisions involve a trade-off between benefits and risks. However, the implementation of SDM in oncology care is challenging, and clinicians state that it is difficult to apply SDM in their actual workplace. Training clinicians is known to be an effective means of improving SDM but is considered time consuming.

Objective

This study aims to address the effectiveness of an individual SDM training program using the concept of deliberate practice.

Methods

This multicenter, single-blinded randomized clinical trial will be performed at 12 Dutch hospitals. Clinicians involved in decisions with oncology patients will be invited to participate in the study and allocated to the control or intervention group. All clinicians will record 3 decision-making processes with 3 different oncology patients. Clinicians in the intervention group will receive the following SDM intervention: completing e-learning, reflecting on feedback reports, performing a self-assessment and defining 1 to 3 personal learning questions, and participating in face-to-face coaching. Clinicians in the control group will not receive the SDM intervention until the end of the study. The primary outcome will be the extent to which clinicians involve their patients in the decision-making process, as scored using the Observing Patient Involvement–5 instrument. As secondary outcomes, patients will rate their perceived involvement in decision-making, and the duration of the consultations will be registered. All participating clinicians and their patients will receive information about the study and complete an informed consent form beforehand.

Results

This trial was retrospectively registered on August 03, 2021. Approval for the study was obtained from the ethical review board (medical research ethics committee Delft and Leiden, the Netherlands [N20.170]). Recruitment and data collection procedures are ongoing and are expected to be completed by July 2022; we plan to complete data analyses by December 2022. As of February 2022, a total of 12 hospitals have been recruited to participate in the study, and 30 clinicians have started the SDM training program.

Conclusions

This theory-based and blended approach will increase our knowledge of effective and feasible training methods for clinicians in the field of SDM. The intervention will be tailored to the context of individual clinicians and will target the knowledge, attitude, and skills of clinicians. The patients will also be involved in the design and implementation of the study.

Trial Registration

Netherlands Trial Registry NL9647; https://www.trialregister.nl/trial/9647

International Registered Report Identifier (IRRID)

DERR1-10.2196/35543

Telehealth and Medical Student Education in the Time of COVID-19-and Beyond

The COVID-19 pandemic continues to limit medical students' full reintegration into clinical learning environments, thus exacerbating an ongoing challenge in identifying a robust number of clinical educational activities at excellent clinical sites for all students. Because medical students across the United States were removed from direct patient care activities in mid-March 2020 due to COVID-19, medical centers have prioritized and implemented changes to the process of patient care. As some barriers are being lifted in the face of a highly contagious and deadly infection, the use of telehealth (delivery of health services remotely via telephone, video, and secure messaging), although not new, is rapidly expanding into all aspects of patient care. Health care providers have been encouraged to conduct many interactions at a physical distance. Telehealth largely replaced face-to-face visits for nonemergency care in an attempt to slow viral transmission while enabling physicians to continue to deliver patient education, manage acute and chronic illness, and nurture caring doctor-patient relationships. Health care providers, many of whom were initially reluctant to embrace telehealth technology and logistics, are becoming nimbler and more aware of the many positive aspects of telehealth. The authors suggest that integrating medical students into telehealth activities would help maintain and improve patients' health, extend the capabilities of health care teams and systems during and after the pandemic, and increase medical students' opportunities for experiential learning and professional identity formation. The authors expand on these 3 goals, suggest several concrete student telehealth activities, propose a curricular strategy, and outline opportunities to overcome key barriers to full alignment of telehealth and undergraduate medical education.

Competency-Based Education: Developing an Advanced Competency Framework for Indonesian Pharmacists

Introduction: Pharmacists need to be adaptable, flexible, and capable of advancing their practice to adapt to rapidly changing population health needs. We describe an educational approach to pharmacy workforce transformation in Indonesia through an advanced practice competency framework development using an "adopt and adapt" methodology. Methods: The competency framework development process comprised a translation phase, an adopt and adapt phase, validation through a nationwide mapping survey, and a completion phase through leadership consensus panels. We conducted a forward-backwards translation of a previously validated Advanced to Consultancy Level Framework (ACLF) to yield the Indonesian Advanced Development Framework (IADF) draft. The subsequent adoption and adaptation process was conducted through a series of consensus panels. We validated the IADF through a nationwide workforce survey. The final phase included leadership consensus panels with the professional leadership body in Indonesia. We analyzed the qualitative data thematically and the quantitative data using a Multiple Correspondence Analysis (MCA) technique. Results: We identified conceptual challenges in adopting and adapting the existing ACLF, which were addressed by providing a national glossary and concrete examples. A total of 6,212 pharmacists participated in the national workforce survey, of which 43% had <2 years of post-license (post-registration) experience. The MCA results showed that practitioner self-assessment to the IADF could discriminate their career development stages. The results also indicated a four-stage career model (including early years career training). Embedding this model in a structured national training program will enhance the professional workforce development through a more structured career journey. Conclusions: We describe the first validation of an advanced competency development framework for the pharmacy workforce in a non-Anglophone country, showing the possibility of transnational applicability of this framework. We argue that this methodology can be used in Low and Middle-income countries (LMICs) for the more rapid advancement of pharmaceutical care practice.

Content and Face Validation of a Novel, Interactive Nutrition Specific Physical Exam Competency Tool (INSPECT) to Evaluate Registered Dietitians' Competence: A Delphi Consensus from the United States

The nutrition-focused physical examination (NFPE) is an integral component of nutrition assessment performed by registered dietitian nutritionists (RDNs) to determine signs of malnutrition and other nutrition-related complications. Increased use of this essential skill among RDNs and the transformation of dietetics education to a competency-based model in the near future calls for appropriately validated tools to measure RDNs' NFPE competence. To fill the need for a validated competency tool, this study developed an Interactive Nutrition-Specific Physical Exam Competency Tool (INSPECT) utilizing the initial 70 items identified in the first phase of the study. The second phase of this study aimed to test the preliminary version of the INSPECT for content and face validity. An expert panel of 17 members provided consensus recommendations through the Delphi process. Internal consistency of the consensus was measured with Cronbach's alpha (α) and α of ≥0.70 was defined as acceptable a priori. Inter-rater agreement among the expert panel was determined using the intraclass correlation coefficient (ICC) and an a priori ICC of 0.75 to 0.9 was established as good and >0.9 as excellent agreement. The results showed acceptable face validity (α = 0.71) and excellent content validity for the INSPECT, with an internal consistency of α = 0.97 in the first round and α = 0.96 in the second round. The inter-rater agreement was also excellent with ICC = 0.95 for each of the Delphi rounds. A total of 52 items were retained from the preliminary version of the INSPECT. Open feedback from the experts allowed for the consolidation of 11 similar items for better scoring and evaluation and thus, a total of 41 items were included in the final version of the INSPECT. The final version of the INSPECT is currently being studied in real-life, multi-site clinical settings among practicing RDNs to examine construct validity, reliability, and item-level psychometric properties. Ultimately, the validated INSPECT will be available for the competency evaluation of RDNs practicing in clinical settings.

A Dynamic Risk Management Approach for Reducing Harm From Invasive Bedside Procedures Performed During Residency

Internal medicine (IM) residents frequently perform invasive bedside procedures during residency training. Bedside procedure training in IM programs may compromise patient safety. Current evidence suggests that IM training programs rely heavily on the number of procedures completed during training as a proxy for resident competence instead of using objective postprocedure patient outcomes. The authors posit that the results of procedural training effectiveness should be reframed with outcome metrics rather than process measures alone. This article introduces the as low as reasonably achievable (ALARA) approach, which originated in the nuclear industry to increase safety margins, to help assess and reduce bedside procedural risks. Training program directors are encouraged to use ALARA calculations to define the risk trade-offs inherent in current procedural training and assess how best to reliably improve patient outcomes. The authors describe 5 options to consider: training all residents in bedside procedures, training only select residents in bedside procedures, training no residents in bedside procedures, deploying 24-hour procedure teams supervised by IM faculty, and deploying 24-hour procedure teams supervised by non-IM faculty. The authors explore how quality improvement approaches using process maps, fishbone diagrams, failure mode effects and analyses, and risk matrices can be effectively implemented to assess training resources, choices, and aims. Future research should address the drivers behind developing optimal training programs that support independent practice, correlations with patient outcomes, and methods that enable faculty to justify their supervisory decisions while adhering to ALARA risk management standards.