The Rural Integrated Community Clerkship: a vital stretch in the Alberta rural physician workforce pipeline.

Background: Longitudinal integrated clerkships are thought to operate synergistically with factors such as rural background and practice intent to determine medical graduates' practice types and locations-sometimes known as the pipeline effect. We examined the influence of the rural integrated community clerkship (ICC) at the University of Alberta on students choosing family medicine and rural practice. Methods: We completed a retrospective cohort analysis of graduates from 2009-2016. The cohort was cross-referenced by background, type of clerkship, practice type and practice location. We used χ2 analyses and risk ratios to measure the relative likelihood that ICC students would settle on rural practice and/or family medicine. Results: ICC participation had more influence than rural background on students' choice of rural and/or family practice, and both factors were synergistic. Rotation-based clerkship students were least likely to enter family medicine or rural practice. Conclusions: The ICC is a clerkship model that influences students to become rural and/or family physicians, regardless of their rural/urban origins. The ICC diverts rural-interested students into rural practice and protects rural-origin students from ending up in urban practice. Expanding ICC infrastructure, including sustaining the rural physician workforce, will benefit rural Alberta communities by increasing the numbers of UA graduates in rural practice.

Contexte: L'externat longitudinal intégré déterminerait, en synergie avec d'autres facteurs, notamment l'origine rurale et l'intention, le type de pratique et le lieu d'exercice des diplômés en médecine, un rapport appelé parfois « effet de pipeline ¼. Nous avons examiné dans quelle mesure l'externat communautaire intégré (ECI) en milieu rural à l'Université de l'Alberta incite les étudiants à choisir la médecine familiale ou l'exercice en milieu rural. Méthodes: Nous avons effectué une analyse de cohorte rétrospective des diplômés de 2009 à 2016. Les données sur la diplomation et celles sur l'origine, le type d'externat, la discipline et le lieu d'exercice ont été croisées. Nous avons utilisé le test du Chi-2 et le rapport de risques pour mesurer la probabilité relative que les étudiants qui ont fait l'ECI choisissent l'exercice en milieu rural et/ou la discipline de la médecine familiale. Résultats: Le fait d'avoir fait l'ECI a été un facteur plus déterminant que l'origine rurale quant au choix des étudiants d'exercer la médecine familiale ou de travailler en milieu rural, mais les deux facteurs étaient synergiques. Les étudiants ayant fait des stages rotatifs étaient les moins susceptibles d'opter pour la médecine familiale ou le milieu rural. Conclusions: L'ECC est un modèle d'externat qui incite les étudiants à se diriger vers la médecine familiale ou l'exercice en milieu rural, et ce, quelle que soit leur origine, rurale ou urbaine. Il amène ceux d'entre eux qui éprouvent déjà un intérêt pour l'exercice en milieu rural à concrétiser ce choix et ceux qui sont d'origine rurale à demeurer dans ce milieu pour y exercer leur profession. Le développement de l'infrastructure de l'ECC et le soutien que l'externat apporte à la main-d'œuvre médicale rurale profiteront aux collectivités rurales en dirigeant un plus grand nombre de diplômés de l'Université de l'Alberta vers l'exercice en milieu rural.

Development of and Preliminary Validity Evidence for the EFeCT Feedback Scoring Tool.

BACKGROUND: Narrative feedback, like verbal feedback, is essential to learning. Regardless of form, all feedback should be of high quality. This is becoming even more important as programs incorporate narrative feedback into the constellation of evidence used for summative decision-making. Continuously improving the quality of narrative feedback requires tools for evaluating it, and time to score. A tool is needed that does not require clinical educator expertise so scoring can be delegated to others. OBJECTIVE: To develop an evidence-based tool to evaluate the quality of documented feedback that could be reliably used by clinical educators and non-experts. METHODS: Following a literature review to identify elements of high-quality feedback, an expert consensus panel developed the scoring tool. Messick's unified concept of construct validity guided the collection of validity evidence throughout development and piloting (2013-2020). RESULTS: The Evaluation of Feedback Captured Tool (EFeCT) contains 5 categories considered to be essential elements of high-quality feedback. Preliminary validity evidence supports content, substantive, and consequential validity facets. Generalizability evidence supports that EFeCT scores assigned to feedback samples show consistent interrater reliability scores between raters across 5 sessions, regardless of level of medical education or clinical expertise (Session 1: n=3, ICC=0.94; Session 2: n=6, ICC=0.90; Session 3: n=5, ICC=0.91; Session 4: n=6, ICC=0.89; Session 5: n=6, ICC=0.92). CONCLUSIONS: There is preliminary validity evidence for the EFeCT as a useful tool for scoring the quality of documented feedback captured on assessment forms. Generalizability evidence indicated comparable EFeCT scores by raters regardless of level of expertise.

Defining rural teaching hospitals in Canada: Developing and testing a new definition.

INTRODUCTION: The current definition of 'teaching hospital' provided by Canadian Institute of Health Information (CIHI) focuses on large academic teaching hospitals. High-quality rural training experiences have been identified as a key component of training the future rural medical workforce. Identifying communities and hospitals where this training is currently available and taking place is important in understanding the current landscape of available rural training but is hampered by the lack of an agreed upon definition of 'rural teaching hospital'. This limits the understanding of current rural training landscapes, comparison across regions and research in this area. We propose a definition of a 'rural teaching hospital'. METHODS: Using the CIHI definition of rural as an initial reference point, we used accessible data from the University of Calgary and University of Alberta Distributed Medical Education (DME) programs to develop a definition of a 'rural teaching hospital'. We then identified rural Alberta hospitals to show how this definition would work in practice. RESULTS: Our definition of a rural teaching hospital is a hospital situated in a town of <30,000 people, teaching occurs at least 36 h a week and that teaching includes at least Family Medicine clerkship OR Family Medicine residency rotations. We identified 104 Alberta rural hospitals. The University of Calgary and University of Alberta DME programs included 70 communities and 44 of these communities met all three proposed criteria for rural teaching hospitals. CONCLUSION: Creating a working definition of a 'rural teaching hospital' is of high importance for both research and for day-to-day operations of rural educational units.

Résumé Introduction: La définition du terme "hôpital d'enseignement " selon l'Institut canadien d'information sur la santé (ICIS) désigne surtout les grands hôpitaux universitaires. L'expérience de formation de bonne qualité en milieu rural est un élément essentiel de la formation du futur personnel médical en milieu rural. Il importe de déterminer quels sont les communautés et les hôpitaux où cette formation a lieu pour comprendre le contexte actuel de la formation rurale offerte, mais l'on se bute à une définition du terme " hôpital d'enseignement rural " qui ne fait pas consensus. Cela limite la compréhension des contextes actuels de formation en milieu rural, la comparaison entre régions et la recherche sur cette question. Nous proposons donc une définition du terme " hôpital d'enseignement rural ". Méthodologie: Avec la définition de l'ICIS de l'adjectif rural comme point de départ, nous avons utilisé les données accessibles des programmes d'éducation médicale satellite de l'Université de Calgary et de l'Université de l'Alberta pour formuler une définition du terme " hôpital d'enseignement rural ". Nous avons ensuite identifié les hôpitaux de l'Alberta pour illustrer comment la définition s'insère dans la pratique. Résultats: Selon nous, un hôpital d'enseignement rural désigne un hôpital situé dans une ville de < 30 000 personnes, l'enseignement y a lieu pendant au moins 36 h par semaine et il inclut au moins un stage en médecine familiale OU des rotations de résidence en médecine familiale. Au total, 104 hôpitaux ruraux de l'Alberta répondaient à cette définition. Les programmes d'éducation médicale satellite de l'Université de Calgary et de l'Université de l'Alberta comptaient 70 communautés et 44 d'entre elles remplissaient les trois critères proposés pour être reconnues avoir un hôpital d'enseignement rural. Conclusion: Il est très important de formuler une définition de travail du terme " hôpital d'enseignement rural " tant pour la recherche que pour les activités quotidiennes des unités d'éducation en milieu rural. Mots-clés: Définitions, éducation médicale satellite, éducation médicale, hôpitaux ruraux.

A clinical nursing rotation transforms medical students' interprofessional attitudes.

This study explores the extent to which a one-week nursing rotation for medical students changed the interprofessional attitudes of the participating nurses and students. Third-year medical students worked with nurses before starting clinical rotations. Pre- and post-experience surveys assessing perceptions of mutual respect, nurse-doctor roles, and interprofessional communication and teamwork were given to 55 nurses and 57 students. The surveys consisted of qualitative questions and a Likert scale questionnaire that was analyzed using qualitative and quantitative content analyses. The response rate was 51/57 (89%) students and 44/55 (80%) nurse preceptors. Nurses reported that students met nurses' expectations by displaying responsibility, respect, effective communication, and an understanding of nursing roles. Medical students' narratives demonstrated two significant changes. First, their views of nurses changed from that of physician helpers to that of collaborative patient-centred professionals. Second, they began defining nursing not by its tasks, but as a caring- and communication-centred profession. Responses to Likert-scaled questions showed significant differences corresponding to changes described in the narrative. A one-week immersive clinical nursing rotation for medical students was a transformative way of learning interprofessional competencies. Learning in an authentic workplace during a clinical rotation engendered mutual respect between nurses and future doctors. Students' view of the role of nurses changed from nurses working for doctors with patients, to working with doctors for patients.

Association of a Competency-Based Assessment System With Identification of and Support for Medical Residents in Difficulty.

Importance: Competency-based medical education is now established in health professions training. However, critics stress that there is a lack of published outcomes for competency-based medical education or competency-based assessment tools. Objective: To determine whether competency-based assessment is associated with better identification of and support for residents in difficulty. Design, Setting, and Participants: This cohort study of secondary data from archived files on 458 family medicine residents (2006-2008 and 2010-2016) was conducted between July 5, 2016, and March 2, 2018, using a large, urban family medicine residency program in Canada. Exposures: Introduction of the Competency-Based Achievement System (CBAS). Main Outcomes and Measures: Proportion of residents (1) with at least 1 performance or professionalism flag, (2) receiving flags on multiple distinct rotations, (3) classified as in difficulty, and (4) with flags addressed by the residency program. Results: Files from 458 residents were reviewed (pre-CBAS: n = 163; 81 [49.7%] women; 90 [55.2%] aged >30 years; 105 [64.4%] Canadian medical graduates; post-CBAS: n = 295; 144 [48.8%] women; 128 [43.4%] aged >30 years; 243 [82.4%] Canadian medical graduates). A significant reduction in the proportion of residents receiving at least 1 flag during training after CBAS implementation was observed (0.38; 95% CI, 0.377-0.383), as well as a significant decrease in the numbers of distinct rotations during which residents received flags on summative assessments (0.24; 95% CI, 0.237-0.243). There was a decrease in the number of residents in difficulty after CBAS (from 0.13 [95% CI, 0.128-0.132] to 0.17 [95% CI, 0.168-0.172]) depending on the strictness of criteria defining a resident in difficulty. Furthermore, there was a significant increase in narrative documentation that a flag was discussed with the resident between the pre-CBAS and post-CBAS conditions (0.18; 95% CI, 0.178-0.183). Conclusions and Relevance: The CBAS approach to assessment appeared to be associated with better identification of residents in difficulty, facilitating the program's ability to address learners' deficiencies in competence. After implementation of CBAS, residents experiencing challenges were better supported and their deficiencies did not recur on later rotations. A key argument for shifting to competency-based medical education is to change assessment approaches; these findings suggest that competency-based assessment may be useful.

Multifaceted support for a new medical school in Nepal devoted to rural health by a Canadian Faculty of Medicine and Dentistry.

Nepal and Alberta are literally a world apart. Yet they share a common problem of restricted access to health services in remote and rural areas. In Nepal, urban-rural disparities were one of the main issues in the recent civil war, which ended in 2006. In response to the need for improved health equity in Nepal a dedicated group of Nepali physicians began planning the Patan Academy of Health Sciences (PAHS), a new health sciences university dedicated to the education of rural health providers in the early 2000s. Beginning with a medical school the Patan Academy of Health Sciences uses international help to plan, deliver and assess its curriculum. PAHS developed an International Advisory Board (IAB) attracting international help using a model of broad, intentional recruitment and then on individuals' natural attraction to a clear mission of peace-making through health equity. Such a model provides for flexible recruitment of globally diverse experts, though it risks a lack of coordination. Until recently, the PAHS IAB has not enjoyed significant or formal support from any single international institution. However, an increasing number of the international consultants recruited by PAHS to its International Advisory Board are from the University of Alberta in Edmonton, Alberta, Canada (UAlberta). The number of UAlberta Faculty of Medicine and Dentistry members involved in the project has risen to fifteen, providing a critical mass for a coordinated effort to leverage institutional support for this partnership. This paper describes the organic growth of the UAlberta group supporting PAHS, and the ways in which it supports a sister institution in a developing nation.

Increasing emergency medicine residents' confidence in disaster management: use of an emergency department simulator and an expedited curriculum.

INTRODUCTION: Disaster Medicine is an increasingly important part of medicine. Emergency Medicine residency programs have very high curriculum commitments, and adding Disaster Medicine training to this busy schedule can be difficult. Development of a short Disaster Medicine curriculum that is effective and enjoyable for the participants may be a valuable addition to Emergency Medicine residency training. METHODS: A simulation-based curriculum was developed. The curriculum included four group exercises in which the participants developed a disaster plan for a simulated hospital. This was followed by a disaster simulation using the Disastermed.Ca Emergency Disaster Simulator computer software Version 3.5.2 (Disastermed.Ca, Edmonton, Alberta, Canada) and the disaster plan developed by the participants. Progress was assessed by a pre- and post-test, resident evaluations, faculty evaluation of Command and Control, and markers obtained from the Disastermed.Ca software. RESULTS: Twenty-five residents agreed to partake in the training curriculum. Seventeen completed the simulation. There was no statistically significant difference in pre- and post-test scores. Residents indicated that they felt the curriculum had been useful, and judged it to be preferable to a didactic curriculum. In addition, the residents' confidence in their ability to manage a disaster increased on both a personal and and a departmental level. CONCLUSIONS: A simulation-based model of Disaster Medicine training, requiring approximately eight hours of classroom time, was judged by Emergency Medicine residents to be a valuable component of their medical training, and increased their confidence in personal and departmental disaster management capabilities.

Competency-based achievement system: using formative feedback to teach and assess family medicine residents' skills.

PROBLEM ADDRESSED: Family medicine residency programs require innovative means to assess residents' competence in "soft" skills (eg, patient-centred care, communication, and professionalism) and to identify residents who are having difficulty early enough in their residency to provide remedial training. OBJECTIVE OF PROGRAM: To develop a method to assess residents' competence in various skills and to identify residents who are having difficulty. PROGRAM DESCRIPTION: The Competency-Based Achievement System (CBAS) was designed to measure competence using 3 main principles: formative feedback, guided self-assessment, and regular face-to-face meetings. The CBAS is resident driven and provides a framework for meaningful interactions between residents and advisors. Residents use the CBAS to organize and review their feedback, to guide their own assessment of their progress, and to discern their future learning needs. Advisors use the CBAS to monitor, guide, and verify residents' knowledge of and competence in important skills. CONCLUSION: By focusing on specific skills and behaviour, the CBAS enables residents and advisors to make formative assessments and to communicate their findings. Feedback indicates that the CBAS is a user-friendly and helpful system to assess competence.

Impact of a nurse practitioner on patient care in a Canadian emergency department.

OBJECTIVE: Our objective was to determine whether the addition of a broad-scope nurse practitioner (NP) would improve emergency department (ED) wait times, ED lengths of stay (LOS) and left-without-treatment (LWOT) rates. We hypothesized that the addition of a broad-scope NP during weekday ED shifts would result in shorter patient wait times, reduced LOS and fewer patients leaving the ED without treatment. METHODS: This prospective observational study was conducted in a busy urban free-standing community ED. Intervention shifts, with NP coverage, were compared with control shifts (similar shifts with emergency physicians [EPs] working independently). Primary outcomes included patient wait times, ED LOS and LWOT rates. Patient demographics, triage category, the provider seen, the time to provider and ED LOS were captured using an electronic database. RESULTS: The addition of an NP was associated with a 12% increase in patient volume per shift and a 7-minute reduction in mean wait times for low-acuity patients. However, overall patient wait times and ED LOS did not differ between intervention and control shifts. During intervention shifts, EPs saw a smaller proportion of low-acuity patients and there was a trend toward a lower proportion of LWOT patients (11.9% v. 13.7%, p = 0.10). CONCLUSION: Adding a broad-scope NP to the ED staff may lower the proportion of patients who leave without treatment, reduce the proportion of low-acuity patients seen by EPs and expedite throughput for a subgroup of less urgent patients. However, it did not reduce overall wait times or ED LOS in this setting.

Introducing a nurse practitioner into an urban Canadian emergency department.

OBJECTIVE: Our objective was to compare the emergency care provided by a nurse practitioner (NP) with that provided by emergency physicians (EPs), to identify emergency department (ED) patients appropriate for autonomous NP practice and to acquire data to facilitate the development of the clinical scope of practice recommendations for ED practice for NPs. METHODS: Using a comprehensive 3-part process, we selected and hired the best NP from 12 applicants. The NP was oriented to the operations of our free-standing community ED and incorporated in the care team, working in real time with EP preceptors during a 6-month, prospective clinical assessment comparing NP care with EP care. ED preceptors reviewed every case in real time with the NP and completed an explicit evaluation form to determine whether NP assessment, investigation, treatment and disposition were "all equivalent to emergency physician care" (AEEPC) or whether they differed. The proportion of AEEPC interactions was determined for 23 patient presentation categories. Our a priori assumption was that a patient presentation category might be suitable for autonomous NP practice if 50% of NP encounters in that category were rated as AEEPC. Descriptive data were presented for patient case mix, teaching domains and time criteria. RESULTS: Eighty-three NP shifts and 711 patient encounters were evaluated by 21 EP preceptors. The NP saw a median of 8 patients per shift. In 43% of encounters, NP care was AEEPC. Highest AEEPC rates were found in the patient follow-up categories general follow-up (55.4%), diagnostic imaging (91.7%) and microbiology laboratory results (87.6%). NP scores over 50% were also seen for lacerations (63.6%) and isolated sore throats (53%). With teaching, NP performance improved over time. CONCLUSION: With the exception of follow up-related complaints, simple lacerations and isolated sore throats, NP care differed substantially from EP care. Although NPs with extensive emergency experience and training might ultimately be able to function as autonomous ED care providers, Canadian EDs currently developing job descriptions for emergency NPs should focus on a model of collaborative practice with EPs.