Health professions education as a discipline: Evidence based on Krishnan's framework.

Health professions education (HPE) emerged as a specific domain of higher education in the 1960s. The interim decades brought the development of advanced training in health professions education and the implementation of HPE offices at many institutions of healthcare and education across the world. Despite these advancements, organizations considering the establishment of HPE offices, or advanced HPE training programs are still challenged by approving authorities to demonstrate that HPE is a discipline and not simply a branch of higher education. Although other scholars have proposed defined characteristics to guide the recognition of study fields as separate academic disciplines, Krishnan's framework is easily operationalized and its use has been broadly reported in the management, education, and intelligence studies literature, among others. Krishnan contends that an academic discipline generally presents the following characteristics: (1) an object of study and research that, although particular to the discipline, can be common to others; (2) a body of specialized knowledge, relative to the subject of study and research, typically unique to the discipline; (3) theories and concepts that frame and organize the specialized knowledge of the discipline; (4) specific terminologies or technical language related to the subject of study and research; (5) research methods adapted to the particular demands of the discipline; and (6) an institutional presence demonstrated by teaching at the graduate level of subjects specific to the discipline, and by the existence of academic departments and professional associations. The purpose of this paper is to present arguments in support of the status of HPE as an academic discipline using Krishnan's framework. It is our hope that these arguments will facilitate the efforts of organizations planning for the establishment of HPE offices or advanced HPE training programs at their institutions.

Impact of accreditation on Caribbean medical schools' processes.

BACKGROUND: Caribbean graduates contribute significantly to the US healthcare workforce. The accreditation requirements of local governments vary from one Caribbean island to another island. The Educational Commission for Foreign Medical Graduates (ECFMG) requirement that all future applicants be graduates from accredited medical schools drove Caribbean medical schools to seek accreditation. Accreditation has been found to significantly impact the educational processes of Canadian medical schools. Our study aims at investigating Caribbean medical school leaders' perceptions of the impact of accreditation on their school's processes. METHODS: This qualitative study and data analysis were done using a framework analysis. Academic leaders and faculty members from three different types of Caribbean medical schools (accredited, denied-accreditation schools, never applied for accreditation) were interviewed using semi-structured interviews. RESULTS: A total of 12 participants from six different Caribbean medical schools participated in the interview process. Themes of processes influenced by accreditation at Caribbean medical schools were similar to those found in the Canadian context and align with best practices of Continuous Quality Improvement (CQI). CONCLUSIONS: Caribbean medical schools are changing their educational processes as a result of accreditation requirements. Some processes are not maintained in a continuous manner, raising questions about the development of a true CQI culture.

CONTEXTE: Les diplômés des Caraïbes contribuent de manière significative au personnel de santé Américain. Les exigences des gouvernements Caraïbes en matière d'agrément varient d'une île à l'autre. L'Educational Commission for Foreign Medical Graduates, ECFMG (Commission de l'éducation pour les diplômés en médecine étrangers), exige que les candidats soient diplômés de facultés de médecine agréées, ce qui a incité les facultés de médecine des Caraïbes à solliciter l'agrément. Il a été démontré que l'agrément affectait de manière importante les processus éducatifs des écoles de médecine canadiennes. Notre étude vise à examiner les perceptions des directions des facultés de médecine des Caraïbes quant aux répercussions de l'agrément sur leurs processus. MÉTHODES: La présente étude qualitative et l'analyse des données ont été réalisées selon la méthodologie du cadre logique. Les responsables universitaires et les membres du corps professoral de facultés de médecine des Caraïbes se trouvant dans trois cas de figure différents (facultés agrées, facultés auxquelles l'agrément a été refusé et facultés n'ayant jamais sollicité l'agrément) ont été interrogés par le biais d'entretiens semi-structurées. RÉSULTATS: Douze participants de six facultés de médecine de la région des Caraïbes ont participé aux entretiens. Des thèmes similaires se dégagent en ce qui concerne les processus influencés par l'agrément dans les facultés de médecine caribéennes et canadiennes, en particulier l'adoption des pratiques exemplaires en matière d'amélioration continue de la qualité (ACQ). CONCLUSIONS: Les facultés de médecine des Caraïbes modifient leurs processus éducatifs afin de remplir les exigences d'agrément. Certains processus ne sont pas maintenus de manière continue, ce qui soulève des interrogations quant à l'implantation d'une véritable culture de l'ACQ.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

BACKGROUND: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25619.

The role of accreditation in 21st century health professions education: report of an International Consensus Group.

BACKGROUND: Accreditation is considered an essential ingredient for an effective system of health professions education (HPE) globally. While accreditation systems exist in various forms worldwide, there has been little written about the contemporary enterprise of accreditation and even less about its role in improving health care outcomes. We set out to 1) identify a global, contemporary definition of accreditation in the health professions, 2) describe the relationship of educational accreditation to health care outcomes, 3) identify important questions and recurring issues in twenty-first century HPE accreditation, and 4) propose a framework of essential ingredients in present-day HPE accreditation. METHODS: We identified health professions accreditation leaders via a literature search and a Google search of HPE institutions, as well as by accessing the networks of other leaders. These leaders were invited to join an international consensus consortium to advance the scholarship and thinking about HPE accreditation. We describe the consensus findings from the International Health Professions Accreditation Outcomes Consortium (IHPAOC). RESULTS: We define accreditation as the process of formal evaluation of an educational program, institution, or system against defined standards by an external body for the purposes of quality assurance and enhancement. In the context of HPE, accreditation is distinct from other forms of program evaluation or research. Accreditation can enhance health care outcomes because of its ability to influence and standardize the quality of training programs, continuously enhance curriculum to align with population needs, and improve learning environments. We describe ten fundamental and recurring elements of accreditation systems commonly found in HPE and provide an overview of five emerging developments in accreditation in the health professions based on the consensus findings. CONCLUSIONS: Accreditation has taken on greater importance in contemporary HPE. These consensus findings provide frameworks of core elements of accreditation systems and both recurring and emerging design issues. HPE scholars, educators, and leaders can build on these frameworks to advance research, development, and operation of high-quality accreditation systems worldwide.

Responsiveness to societal needs in postgraduate medical education: the role of accreditation.

BACKGROUND: Social accountability in medical education has been defined as an obligation to direct education, research, and service activities toward the most important health concerns of communities, regions, and nations. Drawing from the results of a summit of international experts on postgraduate medical education and accreditation, we highlight the importance of local contexts in meeting societal aims and present different approaches to ensuring societal input into medical education systems around the globe. MAIN TEXT: We describe four priorities for social responsiveness that postgraduate medical education needs to address in local and regional contexts: (1) optimizing the size, specialty mix, and geographic distribution of the physician workforce; (2) ensuring graduates' competence in meeting societal goals for health care, population health, and sustainability; (3) promoting a diverse physician workforce and equitable access to graduate medical education; and (4) ensuring a safe and supportive learning environment that promotes the professional development of physicians along with safe and effective patient care in settings where trainees participate in care. We relate these priorities to the values proposed by the World Health Organization for social accountability: relevance, quality, cost-effectiveness, and equity; discuss accreditation as a lever for change; and describe existing and evolving efforts to make postgraduate medical education socially responsive. CONCLUSION: Achieving social responsiveness in a competency-based postgraduate medical education system requires accrediting organizations to ensure that learning emphasizes relevant competencies in postgraduate curricula and educational experiences, and that graduates possess desired attributes. At the same time, institutions sponsoring graduate medical education need to provide safe and effective patient care, along with a supportive learning and working environment.

The Relationship Between Accreditation Cycle and Licensing Examination Scores: A National Look.

PURPOSE: Accreditation aims to ensure all training programs meet agreed-upon standards of quality. The process is complex, resource intensive, and costly. Its benefits are difficult to assess because contextual confounds obscure comparisons between systems that do and do not include accreditation. This study explores accreditation's influence "within system" by investigating the relationship between accreditation cycle and performance on a national licensing examination. METHOD: Scores on the computer-based portion of the Medical Council of Canada Qualifying Examination Part I, from 1993 to 2017, were examined for all 17 Canadian medical schools. Typically completed upon graduation from medical school, results within each year were transformed for comparability across administrations and linked to timing within each school's accreditation cycle. ANOVAs were used to assess the relationship between accreditation timing and examination scores. Secondary analyses isolated 4-year from 3-year training programs and separated data generated before versus after implementation of a national midcycle informal review program. RESULTS: Performance on the licensing exam was highest during and shortly after an accreditation site visit, falling significantly until the midpoint in the accreditation cycle (d = 0.47) before rising again. This pattern disappeared after introduction of informal interim review, but too little data have accumulated post implementation to determine if interim review is sufficient to break the influence of accreditation cycle. CONCLUSIONS: Formal, externally driven, accreditation cycles appear associated with educational processes in ways that translated into student outcomes on a national licensing examination. Whether informal, internal, interim reviews can mediate this effect remains to be seen.

Measuring the continuous quality improvement orientation of medical education programs.

PURPOSE: There is a growing interest in applying continuous quality improvement (CQI) methodologies and tools to medical education contexts. One such tool, the "Are We Making Progress" questionnaire from the Malcolm Baldrige National Quality Award framework, adequately captures the dimensions critical for performance excellence and allows organizations to assess their performance and identify areas for improvement. Its results have been widely validated in business, education, and health care and might be applicable in medical education contexts. The measurement properties of the questionnaire data were analyzed using Rasch modeling to determine if validity evidence, based on Messick's framework, supports the interpretation of results in medical education contexts. Rasch modeling was performed since the questionnaire uses Likert-type scales whose estimates might not be amenable to parametric statistical analyses. DESIGN/METHODOLOGY/APPROACH: Leaders and teachers at 16 of the 17 Canadian medical schools were invited in 2015-2016 to complete the 40-item questionnaire. Data were analyzed using the ConQuest Rasch calibration program, rating scale model. FINDINGS: 491 faculty members from 11 (69 percent) schools participated. A seven-dimensional, four-point response scale model better fit the data. Overall data fit to model requirements supported the use of person measures with parametric statistics. The structural, content, generalizability, and substantive validity evidence supported the interpretation of results in medical education contexts. ORIGINALITY/VALUE: For the first time, the Baldrige questionnaire results were validated in medical education contexts. Medical education leaders are encouraged to serially use this questionnaire to measure progress on their school's CQI focus.

Accreditation of Canadian Undergraduate Medical Education Programs: A Study of Measures of Effectiveness.

PURPOSE: Undergraduate medical education (UME) programs participate in accreditation with the belief that it contributes to improving UME quality and, ultimately, patient care. Linkages between accreditation and UME quality are incomplete. Previous studies focused on student performance on national examinations, medical school processes, medical school's organizational culture types, and degree of implementation of quality improvement activities as markers of the effectiveness of accreditation. The current study sought to identify new indicators of accreditation effectiveness, to better understand the value and impact of accreditation. METHOD: This qualitative study used an expert-oriented evaluation approach to identify novel markers of accreditation effectiveness. From March 2015 to March 2016, leaders and teachers at 16 of the 17 Canadian UME programs were invited to participate in interviews and focus group discussions aimed at identifying measures of accreditation effectiveness. Themes were extracted using the method of constant comparative analysis. RESULTS: Sixty-three individuals from 13 (81%) medical schools participated. Eight themes were formulated: Student/graduate performance, UME program processes, quality assurance and continuous quality improvement, stakeholder satisfaction, stakeholder expectations, engagement, research, and UME program quality. The latter 5 themes have not been previously studied as measures of accreditation effectiveness. All themes appear applicable to accreditation of graduate medical education as well. A framework is proposed to guide future research on the impact of accreditation. CONCLUSIONS: Eight themes were generated, representing direct and indirect indicators of the impact of accreditation. The themes are integrated into a framework proposed to guide future research on the value of accreditation along the continuum of medical education.

Resident Physician Wellness Curriculum: A Study of Efficacy and Satisfaction.

Background Recent literature highlights the alarming prevalence of burnout, depression, and illness during residency training; a trend that is also linked to suboptimal patient care. Dedicated wellness curricula may be one solution to this concerning issue. Purpose To determine the effect of a multi-faceted wellness curriculum during emergency medicine residency training on wellness scores and to assess resident satisfaction with the program. Methods This study was conducted via a longitudinal survey. In 2009, a faculty-derived resident wellness curriculum (F-RWC) was initiated. This program was then bolstered with a parallel resident-derived curriculum (R-RWC) one year later, in 2010. Emergency medicine residents were surveyed in 2009, 2010, and 2011 to assess wellness at baseline, after one year of the F-RWC, and after one year of combined RWCs, respectively. Surveys included two validated assessment instruments (the Brief Resident Wellness Profile (BRWP) and the SF-8TM Health Survey), a satisfaction Likert scale, and a demographics information sheet. Results The survey response rates were 89% (n=17), 100% (n=17), and 83% (n=24) from 2009, 2010, and 2011, respectively, for a total of 58 participants. From baseline in 2009, there was a significant improvement in resident wellness, with the addition of parallel RWC by 2011, as measured by the BRWP (p=0.024). The faces scale, a subset of the BRWP, showed a trend toward benefit but did not reach statistical significance (p=0.085). There was no evidence of a statistically significant change in SF-8TM scores over time. Participants consistently reported positive satisfaction scores with RWC initiatives. Conclusions Dedicated RWC, with input from both faculty and resident physicians, improved wellness during residency training with a high degree of participant satisfaction. Such programs are needed to support resident physicians during their training.

Quality improvement in medical schools: vision meets culture.

CONTEXT: Medical schools face growing pressures to develop quality improvement (QI) strategies to ensure the continuous quality of their education. To best achieve quality, both organisational processes and culture need to be oriented towards quality. Quality processes already exist at medical schools, at least externally driven by accreditation. However, the dominant culture in most medical schools is not typically oriented towards quality. OBJECTIVES: This study explores whether QI practices are recognised as such in organisations not culturally QI-oriented. Specifically, it examines faculty members' perceptions about the degree of QI implementation in their medical education programmes. Understanding this perception will inform medical school leadership on how best to use resources for a successful execution of the school's QI vision. METHODS: Leaders, clinical teachers and formal teachers at 16 of the 17 Canadian medical schools were invited to complete the 'Are We Making Progress?' questionnaire of the Malcolm Baldrige National Quality Award framework, the results of which have been broadly validated. The questionnaire measures the perceived level of QI implementation within organisations using 40 statements grouped under the framework's seven domains of performance excellence. RESULTS: A total of 491 respondents from 11 (69%) schools completed the questionnaire; 173 (35%) identified as clinical teachers, 150 (31%) as formal teachers, and 168 (34%) as leaders. Perceived QI implementation levels were low across programmes (0.70-1.90 in Rasch person measures) and for each category of respondents. This was especially true for the domains of 'Strategy', 'Measurement/analysis/knowledge management' and 'Operations'. Leaders' perceptions of QI implementation were higher than those of teachers. CONCLUSIONS: Medical schools' existing QI processes are not recognised as QI activities. For QI strategies to succeed, a programme's culture must embrace QI. In the execution of their QI visions, medical schools should spend resources on embedding quality in the organisation culture in addition to strengthening existing QI practices, especially in the domains listed above.

Do organizational cultures of Canadian medical schools promote a quality culture?

Purpose: Medical schools are expected to engage in ongoing reflection to maintain the quality of the education they deliver, that is, to cultivate a Quality Culture. Quality Culture integrates the culture of an organization with its structure and management processes. The culture of medical schools has not been previously studied. Organizational cultures can be identified using the Competing Value Questionnaire, and classified into four types, based on organizations' climate, leader style, reward systems, and strategic emphasis. Clan and Open cultures are typically positively associated with quality improvement. This study identifies the dominant organizational cultures of Canadian medical schools. Method: Sixteen of the 17 Canadian medical schools were invited to participate; one school was excluded due to ongoing accreditation activities. Faculty members of participating schools were surveyed. Results: Eleven (69%) schools participated. Nine had a dominant Hierarchical culture; two had a dominant Clan culture. Conclusions: Only two schools had a Clan culture, which might better support ongoing reflections on quality improvement. Schools leaders should examine the staff climate, leadership style, rewards system, and strategic emphasis in place at their school; these will provide clues to the existing culture and help prioritize changes required to support the implementation of a Quality Culture.

Impact of interpersonal relations on learning and development of professional identity: A study of residents' perceptions.

OBJECTIVES: Informal learning includes all occurrences during one's life when learning is not deliberate. Prior research on informal learning in healthcare contexts examined learning happening outside of the formal curriculum, yet still in the workplace. This study explores residents' perceptions about extracurricular factors outside of the workplace that contribute to their learning and development of professional identity, whether interpersonal relations are recognised as such factors, and positive and negative impacts of interpersonal relations. METHODS: In this qualitative study, all 21 residents in our Emergency Medicine programme were asked, in a web-based survey with open-ended questions, to identify extracurricular sources outside of the workplace perceived as contributing to their learning and professional identity development, and list positive and negative impacts of interpersonal relations outside of work on learning and identity development. Themes were extracted through content analysis of the narrative responses. Two reviewers coded all data. RESULTS: Thirteen (62%) residents identified 37 factors grouped under five themes: learning activity, role modelling, support, non-clinical academic roles, and social interactions. Interpersonal relations were perceived as having positive and negative impacts, including creating support, positive role modelling and mentoring, increasing concrete learning, as well as lapses in teaching skills, deficits in professional role training, and loss of personal time. CONCLUSIONS: Several extracurricular factors outside of the workplace contribute to resident learning and identity development, including interpersonal relations, which have positive and negative impacts. The most often noted negative impact of interpersonal relations outside of work between residents and faculty related to perceived lapses in teaching skills.

The impact of accreditation on medical schools' processes.

OBJECTIVES: Increased emphasis is being placed worldwide on accreditation of undergraduate medical education programmes, and costs of participation in accreditation continue to rise. The primary purposes of accreditation are to ensure the quality of medical education and to promote quality improvement. Student performance data as indicators of the impact of accreditation have important limitations. The purpose of this study was to evaluate the impact of accreditation using an innovative marker: the processes implemented at medical schools as a result of accreditation. This conceptual model suggests that accreditation drives medical schools to implement and strengthen processes that support quality in medical education. METHODS: In this qualitative study, conducted in 2015-2016, interviews and focus group discussions with deans, undergraduate medical education deans and faculty leaders at 13 of the 17 Canadian medical schools were used to elicit perspectives about processes influenced by accreditation; the method of constant comparative analysis associated with grounded theory was used to generate themes of processes. Perceived negative consequences of accreditation on medical education programmes were also explored. RESULTS: Nine themes representing processes reported as resulting from accreditation were identified. These processes related to: (i) governance, (ii) data collection and analysis, (iii) monitoring, (iv) documentation, (v) creation and revision of policies and procedures, (vi) continuous quality improvement, (vii) faculty members' engagement, (viii) academic accountability and (ix) curriculum reforms. Themes representing negative consequences of accreditation included (i) costs, (ii) staff and faculty members' morale and feelings, (iii) school reputation and (iv) standards. The identified processes, given their nature, appear likely to be associated with improvement of quality in medical education. These results help justify the costs associated with accreditation. CONCLUSIONS: This study uses an innovative marker, medical schools' processes, to evaluate the impact of accreditation. Results provide evidence that accreditation-related activities steer medical education programmes towards establishment of processes likely to be associated with improved quality in medical education.

Accreditation of Medical Education Programs: Moving From Student Outcomes to Continuous Quality Improvement Measures.

Accreditation of undergraduate medical education programs aims to ensure the quality of medical education and promote quality improvement, with the ultimate goal of providing optimal patient care. Direct linkages between accreditation and education quality are, however, difficult to establish. The literature examining the impact of accreditation predominantly focuses on student outcomes, such as performances on national examinations. However, student outcomes present challenges with regard to data availability, comparability, and contamination.The true impact of accreditation may well rest in its ability to promote continuous quality improvement (CQI) within medical education programs. The conceptual model grounding this paper suggests accreditation leads medical schools to commit resources to and engage in self-assessment activities that represent best practices of CQI, leading to the development within schools of a culture of CQI. In line with this model, measures of the impact of accreditation on medical schools need to include CQI-related markers. The CQI orientation of organizations can be measured using validated instruments from the business and management fields. Repeated determinations of medical schools' CQI orientation at various points throughout their accreditation cycles could provide additional evidence of the impact of accreditation on medical education. Strong CQI orientation should lead to high-quality medical education and would serve as a proxy marker for the quality of graduates and possibly for the quality of care they provide.It is time to move away from a focus on student outcomes as measures of the impact of accreditation and embrace additional markers, such as indicators of organizational CQI orientation.

A National Faculty Development Needs Assessment in Emergency Medicine.

OBJECTIVES: Emergency physicians who work in academic settings enjoy an expanding number of roles beyond that of the skilled clinician. Faculty development (FD) encompasses the broad range of activities that institutions use to renew skill-sets and assist faculty members in these multiple roles. This study seeks to define the current FD needs and interests of Canadian academic emergency physicians (AEPs). METHODS: An online survey was administered to 943 AEPs in eight centers across Canada to determine their current FD activities, provide a detailed understanding of their FD needs and interests, elucidate the perceived barriers to and motivation for engaging in FD, and identify preferred methods of delivery for FD activities. RESULTS: This national, cross-sectional survey was completed by 336 respondents. It shows that need for FD is universally high, particularly in traditional domains of scholarship, leadership and education (79%, 80%, 87% overall interest, respectively). However, the study also suggests that there is increasing need for FD in areas where current participation is lowest, namely research and social accountability (12% and 13% more interest, respectively). Senior and junior faculty evince equivalent overall FD interest (p>0.05), whereas female AEPs expressed greater overall FD needs in leadership (1.82 vs 1.44 activities, p=0.003) than males. Continued participation in FD activities is best promoted by offering relevant topics, at convenient times and locations. CONCLUSIONS: This study reports the first comprehensive national FD needs assessment of Canadian academic emergency physicians.

Emergency medicine residents' beliefs about contributing to an online collaborative slideshow.

OBJECTIVE: Collaborative writing applications (CWAs), such as the Google DocsTM platform, can improve skill acquisition, knowledge retention, and collaboration in medical education. Using CWAs to support the training of residents offers many advantages, but stimulating them to contribute remains challenging. The purpose of this study was to identify emergency medicine (EM) residents' beliefs about their intention to contribute summaries of landmark articles to a Google DocsTM slideshow while studying for their Royal College of Physicians and Surgeons of Canada (RCPSC) certification exam. METHOD: Using the Theory of Planned Behavior, the authors interviewed graduating RCPSC EM residents about contributing to a slideshow. Residents were asked about behavioral beliefs (advantages/disadvantages), normative beliefs (positive/negative referents), and control beliefs (barriers/facilitators). Two reviewers independently performed qualitative content analysis of interview transcripts to identify salient beliefs in relation to the defined behaviors. RESULTS: Of 150 eligible EM residents, 25 participated. The main reported advantage of contributing to the online slideshow was learning consolidation (n=15); the main reported disadvantage was information overload (n=3). The most frequently reported favorable referents were graduating EM residents writing the certification exam (n=16). Few participants (n=3) perceived any negative referents. The most frequently reported facilitator was peer-reviewed high-quality scientific information (n=9); and the most frequently reported barrier was time constraints (n=22). CONCLUSION: Salient beliefs exist regarding EM residents' intention to contribute content to an online collaborative writing project using a Google DocsTM slideshow. Overall, participants perceived more advantages than disadvantages to contributing and believed that this initiative would receive wide support. However, participants reported several barriers that need to be addressed to increase contributions. Our intention is for the beliefs identified in this study to contribute to the design of a theory-based questionnaire to explore determinants of residents' intentions to contribute to an online collaborative writing project. This will help develop implementation strategies for increasing contributions to other CWAs in medical education.

Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians?

PURPOSE: Others have suggested that increased time pressure, sometimes caused by interruptions, may result in increased diagnostic errors. The authors previously found, however, that increased time pressure alone does not result in increased errors, but they did not test the effect of interruptions. It is unclear whether experience modulates the combined effects of time pressure and interruptions. This study investigated whether increased time pressure, interruptions, and experience level affect diagnostic accuracy and response time. METHOD: In October 2012, 152 residents were recruited at five Medical Council of Canada Qualifying Examination Part II test sites. Forty-six emergency physicians were recruited from one Canadian and one U.S. academic health center. Participants diagnosed 20 written general medicine cases. They were randomly assigned to receive fast (time pressure) or slow condition instructions. Visual and auditory case interruptions were manipulated as a within-subject factor. RESULTS: Diagnostic accuracy was not affected by interruptions or time pressure but was related to experience level: Emergency physicians were more accurate (71%) than residents (43%) (F = 234.0, P < .0001) and responded more quickly (54 seconds) than residents (65 seconds) (F = 9.0, P < .005). Response time was shorter for participants in the fast condition (55 seconds) than in the slow condition (73 seconds) (F = 22.2, P < .0001). Interruptions added about 8 seconds to response time. CONCLUSIONS: Experienced emergency physicians were both faster and more accurate than residents. Instructions to proceed quickly and interruptions had a small effect on response time but no effect on accuracy.