Intimidation, harassment, and discrimination during family medicine residency training: a mixed methods study.

BACKGROUND: The importance of wellbeing of family medicine residents is recognized in accreditation requirements which call for a supportive and respectful learning environment; however, concerns exist about learner mistreatment in the medical environment. The purpose of this study was to to describe family medicine graduates' perceived experience with intimidation, harassment and discrimination (IHD) during residency training. METHODS: A mixed-methods study was conducted on a cohort of family medicine graduates who completed residency training during 2006-2011. Phase 1, the quantitative component, consisted of a retrospective survey of 651 graduates. Phase 2, the qualitative component, was comprised of 11 qualitative interviews. Both the survey and the interviews addressed graduates' experience with IHD with respect to frequency and type, setting, perpetrator, perceived basis for IHD, and the effect of the IHD. RESULTS: The response rate to the survey was 47.2%, with 44.7% of respondents indicating that they experienced some form of mistreatment/IHD during residency training, and 69.9% noting that it occurred more than once. The primary sources of IHD were specialist physicians (75.7%), hospital nurses (47.8%), and family physicians (33.8%). Inappropriate verbal comments were the most frequent type of IHD (86.8%). Graduates perceived the basis of the IHD to be abuse of power (69.1%), personality conflict (36.8%), and family medicine as a career choice (30.1%), which interview participants also described. A significantly greater proportion IMGs than CMGs perceived the basis of IHD to be culture/ethnicity (47.2% vs 10.5%, respectively). The vast majority (77.3%) of graduates reported that the IHD experience had a negative effect on them, consisting of decreased self-esteem and confidence, increased anxiety, and sleep problems. As trainees, they felt angry, threatened, demoralized, discouraged, manipulated, and powerless. Some developed depression or burnout, took medication, or underwent counselling. CONCLUSIONS: IHD continued to be prevalent during family medicine residency training, with it occurring most frequently in the hospital setting and specialty rotations. Educational institutions must work with hospital administrators to address issues of mistreatment in the workplace. Residency training programs and the medical establishment need to be cognizant that the effects of IHD are far-reaching and must continuously work to eradicate it.

Can we predict failure in licensure exams from medical students' undergraduate academic performance?

BACKGROUND: In 2015, the Medical Council of Canada increased the minimum pass level for the Medical Council of Canada Qualifying Examination Part I, and students had a higher rate of failure than in previous years. The purpose of this study was to predict students at an increased odds of examination failure to allow for early, targeted interventions. METHODS: We divided our dataset into a derivation cohort and two validation cohorts and used multiple logistic regression to predict licensing examination failure. We then performed receiver operating characteristics and a sensitivity analysis using different cutoffs for explanatory variables to identify the cutoff threshold with the best predictive value at identifying students at increased odds of failure. RESULTS: After multivariate analysis, only pre-clerkship GPA was a significant independent predictor of failure (OR 0.76, 95% CI [0.66, 0.88], p < 0.001). The probability of failure increased steeply when the pre-clerkship GPA fell below 80% and 76% was found to be the most efficient cutoff for predicting failure (OR 9.37, 95% CI [3.08, 38.41]). CONCLUSIONS: Pre-clerkship performance can predict students at increased odds of licensing examination failure. Further studies are needed to explore whether early interventions for at-risk students alter their examination performance.

CONTEXTE: En 2015, le Conseil médical du Canada a resserré les exigences de réussite à l'examen d'aptitude du Conseil médical du Canada, partie I, entraînant un taux d'échec plus élevé que les années précédentes. L'objectif de cette étude était de détecter les étudiants ayant de plus grande probabilité d'échec à l'examen afin de permettre des interventions ciblées en temps utile. MÉTHODES: Nous avons comparé les données d'une cohorte de dérivation et deux cohortes de validation et nous avons utilisé la régression logistique multiple pour prédire l'échec à l'examen d'aptitude. Nous avons ensuite effectué une analyse de la fonction d'efficacité du récepteur et une analyse de sensibilité en utilisant différents seuils pour les variables explicatives afin de déterminer la meilleure valeur prédictive seuil pour cibler une forte possibilité d'échec chez les étudiants. RÉSULTATS: L'analyse multivariée a révélé que seule la moyenne générale des étudiants était un prédicteur indépendant significatif de l'échec (OR 0.76, 95 % CI [0.66, 0.88], p < 0.001). La probabilité d'échec augmentait fortement lorsque l'indice de moyenne générale tombait en dessous de 80 %. Le seuil le plus efficace pour prédire l'échec s'est avéré être 76 % (OR 9,37, 95 % CI [3,08, 38,41]). CONCLUSIONS: Les résultats scolaires des étudiants en médecine constituent un indicateur de risque d'échec à l'examen d'aptitude. Des études supplémentaires sont nécessaires pour vérifier si une intervention précoce auprès des étudiants à risque peut améliorer leurs résultats à l'examen.

An Axiological Analysis of One Medical School's Admissions Process: Exploring Individual Values and Value Systems.

PURPOSE: Values and value systems are fundamental to medical school admissions processes. An axiological analysis was carried out to explore the individual values and value systems found within the University of Calgary's Cumming School of Medicine's undergraduate admissions process. METHOD: A mixed-methods case study methodology was developed with a focus on applicant characteristics viewed as desirable, the relative value ascribed to applicant characteristics, the values that participants in admissions processes brought to bear, the values that were reflected in the artifacts and procedures used in support of admissions processes, and the values that were expressed at a system, program, or institutional level. The study employed a descriptive audit of admissions processes, a stakeholder survey, stakeholder interviews, and a discourse analysis of admissions materials (all carried out between June and September 2017). RESULTS: The study found that, despite a general sense of satisfaction with the rigor of the admissions process, there was less satisfaction with the final selection it produced. Participants wanted to see more attention paid to responsibilities to patients and society than to gender and ethnic balance. CONCLUSIONS: Those involved with medical school admissions need to be mindful of their value systems and use them to align intent with process and outcomes in selecting tomorrow's physicians. Axiological analysis of medical education processes can play a central role in reviewing and refocusing efforts on meeting an institution's social mission and medical education's social contract.

The grades that clinical teachers give students modifies the grades they receive.

Prior studies have shown a correlation between the grades students receive and how they rate their teacher in the classroom. In this study, the authors probe this association on clinical rotations and explore potential mechanisms. All In-Training Evaluation Reports (ITERs) for students on mandatory clerkship rotations from April 1, 2013 to January 31, 2015 were matched with the corresponding student's rating of their teacher (SRT). The date and time that ITERs and SRTs were submitted was used to divide SRTs into those submitted before versus after the corresponding ITER was submitted. Multilevel, mixed effects linear regression was used to examine the association between SRT, ITER rating, and whether the ITER was submitted before or after SRT. Of 2373 paired evaluations, 1098 (46.3%) SRT were submitted before the teacher had submitted the ITER. There was a significant interaction between explanatory variables: when ITER ratings had not yet been submitted, the regression coefficient for this association was 0.25 (95% confidence interval [0.17, 0.33], p < 0.001), whereas the regression coefficient was significantly higher when ITER ratings were submitted prior to SRT (0.40 [0.31, 0.49], p < 0.001). Finding an association between SRT and ITER when students do not know their ITER ratings suggests that SRTs can capture attributes of effective teaching, but the effect modification when students have access to their ITER rating supports grade satisfaction bias. Further studies are needed to explain the mechanism of grade satisfaction and to identify other biases that may impact the validity of SRT.

Implications of not matching to a first-choice discipline: a family medicine perspective.

BACKGROUND: Family medicine is often selected as an alternate career choice by medical students who do not match to their first choice discipline. Consequently, family medicine residency programs accept and train some residents who prepared for and intended a career in another specialty. The implications of this warrant investigation. METHODS: Graduates (2006-2011) of Albertan family medicine residency programs were surveyed to examine differences between physicians who indicated family medicine was their first choice discipline and those who indicated that it was not their first choice. Survey questions targeted practice location, preparedness for practice, perceptions of family medicine, lifestyle satisfaction, and well-being. Principal components analysis was used to examine the factor structure of our survey items and ANOVA and Chi square were used to compare mean scores and proportions, respectively. RESULTS: The overall response rate was 47.2% (307/651). Most (263) respondents reported that family medicine was their first choice discipline (yes-group); 42 respondents indicated that it was not (no-group) and two did not answer. The two groups were similar demographically. The no-group reported significantly lower mean scores on perceptions of family medicine. There were no significant differences between the two groups in their preparedness for practice and measures of lifestyle satisfaction and well-being. CONCLUSION: Irrespective of their perceptions of the discipline, the respondents who did not match to their first choice discipline found family medicine to be a viable career option.

Well-being of family medicine graduates.

OBJECTIVE: To determine family medicine graduates' professional and personal well-being, general health status, stress levels, coping strategies, and the degree to which they felt supported or isolated in professional life; and to compare findings by sex, practice location, and location of medical school (Canadian medical graduates [CMGs] vs international medical graduates [IMGs]). DESIGN: Retrospective, cross-sectional survey. SETTING: University of Alberta in Edmonton and the University of Calgary in Alberta. PARTICIPANTS: A total of 651 graduates who completed one of the family medicine residency programs during 2006 to 2011. MAIN OUTCOME MEASURES: Using a 5-point Likert scale, graduates rated their general health status, their personal and professional well-being, their level of stress, and the degree to which they felt supported or isolated in professional life. Respondents also identified important life events, their caregiving roles, and stress-coping strategies. RESULTS: Of 651 graduates, 307 (47.2%) responded to the survey. Personal and professional well-being and general health status were rated as very good or excellent by 72.0%, 76.6%, and 74.7% of graduates, respectively. Overall, 39.3% reported high or extremely high levels of stress, with CMGs exhibiting significantly higher stress levels than IMGs (P = .02). Stress scores were inversely related to personal and professional well-being and health status. In terms of coping strategies, a significantly greater proportion of female than male graduates reported talking to colleagues (76.5% vs 64.3%; P = .026) and seeking professional counseling (18.7% vs 6.1%; P = .002). Also, a significantly greater proportion of IMGs than CMGs (52.9% vs 32.5%; P = .003), as well as those in rural (35.8%) or urban (49.3%) practices than those in metropolitan locations (30.1%) (P = .03), turned to spiritual or religious practices for stress management. Of all respondents, 54.8% felt highly or extremely supported and 18.4% felt isolated in their professional lives. CONCLUSION: While family medicine graduates are primarily healthy and have a strong sense of personal and professional well-being, many experience high levels of stress. Coping strategies generally include social contact with family, friends, or colleagues and differ by sex, whether respondents are CMGs or IMGs, and practice location. Professional isolation appears to be prevalent in both rural and urban practice locations. Physician well-being programs should include a multifaceted approach to accommodate a range of physician preferences.

Weighing the cost of educational inflation in undergraduate medical education.

Despite the fact that the length of medical school training has remained stable for many years, the expectations of graduating medical students (and the schools that train them) continue to increase. In this Reflection, the authors discuss motives for educational inflation and suggest that these are likely innocent, well-intentioned, and subconscious-and include both a propensity to increase expectations of ourselves and others over time, and a reluctance to reduce training content and expectations. They then discuss potential risks of educational inflation, including reduced emphasis on core knowledge and clinical skills, and adverse effects on the emotional, psychological, and financial wellbeing of students. While acknowledging the need to change curricula to improve learning and clinical outcomes, the authors proffer that it is naïve to assume that we can inflate educational expectations at no additional cost. They suggest that before implementing and/or mandating change, we should consider of all the costs that medical schools and students might incur, including opportunity costs and the impact on the emotional and financial wellbeing of students. They propose a cost-effectiveness framework for medical education and advocate prioritization of interventions that improve learning outcomes with no additional costs or are cost-saving without adversely impacting learning outcomes. When there is an additional cost for improved learning outcomes or a decline in learning outcomes as a result of cost saving interventions, they suggest careful consideration and justification of this trade-off. And when there are neither improved learning outcomes nor cost savings they recommend resisting the urge to change.

Practice locations of longitudinal integrated clerkship graduates: a matched-cohort study.

INTRODUCTION: Longitudinal integrated clerkships (LICs) have been introduced as an innovative model to impart medical education. In Canada, most LIC experiences are situated in rural communities. Studies have reported equivalence in graduates from rural LICs and traditional rotation-based clerkships (RBCs) in their performance in residency, as well as in national medical licensure examinations. We sought to determine the impact of rural LICs in terms of practice location of graduates. METHODS: A matched cohort was developed on the basis of student background and sex to compare practice location of rural LIC and RBC graduates. We used the χ(2) test to assess the association between type of clerkship stream and practice location. RESULTS: We found an association between participation in a rural LIC and rural practice location. CONCLUSION: Rural LIC programs play an important role in introducing students to rural medicine and may be an effective tool in responding to the shortage of rural practitioners.

INTRODUCTION: Les stages cliniques longitudinaux intégrés (SCLI) ont été introduits à titre de modèles de formation médicale novateurs. Au Canada, la plupart des expériences de SCLI se déroulent en milieu rural. Des études ont fait état d'une équivalence entre les diplômés ayant opté pour un SCLI en milieu rural ou l'habituel stage clinique hospitalier (SCH) pour ce qui est de leur rendement durant leur résidence et de leurs résultats aux examens nationaux menant à l'obtention du permis d'exercice. Nous avons voulu mesurer l'impact des SCLI en milieu rural sur le lieu de pratique des diplômés. MÉTHODES: Une cohorte assortie a été formée sur la base des antécédents et du sexe des étudiants afin de comparer le lieu de pratique des diplômés selon qu'ils avaient fait un SCLI en milieu rural ou un SCH. Nous avons utilisé le test du χ2 pour évaluer le lien entre le type de stage clinique et le lieu de pratique. RÉSULTATS: Nous avons découvert un lien entre la participation à un SCLI en milieu rural et la pratique en milieu rural. CONCLUSION: Les programmes de SCLI en milieu rural sont importants pour initier les étudiants à ce type de pratique et pourraient être un outil efficace pour répondre à la pénurie de médecins en milieu rural.

Rural longitudinal integrated clerkships: changing interests and demographics of medical students.

INTRODUCTION: The University of Calgary Longitudinal Integrated Clerkship (UCLIC) is an integrated curriculum of at least 32 weeks' duration based in rural communities. Rural LICs have been proposed as a method to respond to the needs of underserved rural communities; therefore, assessing evolving learner interest and demographics over time is of importance to rural communities. METHODS: Three surveys were administered to first-year medical students at the University of Calgary from the classes of 2009, 2010 and 2015. The surveys assessed demographic information as well as interest in and attitudes toward pursuing a rural-based LIC. RESULTS: Overall, 42% of students (76% of decided students) reported that they would consider the rural UCLIC. Between 2009 and 2010, the proportion of students who would not consider the UCLIC decreased from 25% to 8%, and thereafter was maintained at that level. Over the same period, interest among students considering Royal College of Physicians and Surgeons of Canada (RCPSC) specialties significantly increased. Although student attitudes about the value of the LIC were consistently positive, students remained concerned about social considerations. CONCLUSION: There has been an increase in student willingness to consider a rural LIC, most significantly among students interested in RCPSC specialties. Career plans and demographics of students continue to influence their interest in and attitudes toward LICs.

INTRODUCTION: Le stage intégré longitudinal (SIL) de l'Université de Calgary (ou UCLIC pour University of Calgary Longitudinal Integrated Clerkship) est un programme intégré d'une durée minimale de 32 semaines en communauté rurale. Les SIL ruraux ont été proposés comme moyen de répondre aux besoins des communautés rurales moins bien desservies; il est donc important pour les communautés rurales de suivre l'évolution des intérêts et des caractéristiques démographiques des stagiaires au fil du temps. MÉTHODES: Trois sondages ont été administrés à des étudiants de première année de médecine à l'Université de Calgary des promotions de 2009, 2010 et 2015. Les sondages portaient sur leurs données démographiques de même que sur leur intérêt et leurs attitudes à l'endroit d'un SIL en milieu rural. RÉSULTATS: Dans l'ensemble, 42 % des étudiants (76 % des étudiants décidés) ont déclaré qu'ils envisageraient un SIL en milieu rural. Entre 2009 et 2010, la proportion d'étudiants qui n'envisageaient pas un tel stage a diminué de 25 %, à 8 %, et par la suite s'est maintenue à ce niveau. Au cours de la même période, l'intérêt à l'égard de ce stage chez les étudiants qui envisageaient une spécialisation du Collège royal des médecins et chirurgiens du Canada (CRMCC) a significativement augmenté. Même si leurs attitudes à propos de la valeur d'un SIL sont demeurées favorables, les étudiants ont dit se soucier des enjeux sociaux. CONCLUSION: On a constaté que les étudiants envisagent plus volontiers un SIL en milieu rural s'ils souhaitent faire une spécialisation du CRMCC. Les plans de carrière et les caractéristiques démographiques continuent d'influer sur leurs intérêts et leurs attitudes à l'endroit des SIL.

Changes in Veterinary Students' Attitudes Toward the Rural Environment and Rural Veterinary Practice: A Longitudinal Cohort Study.

There is a paucity of research regarding veterinary students' attitudes toward the rural environment and rural veterinary practice and how these attitudes might change over the course of a veterinary medicine program that includes rural clinical experience. Using a 23-item questionnaire, attitudes toward rural lifestyle, rural work-life balance, opportunities for career and skill development in rural veterinary practice, and inter-professional teamwork in the rural environment were assessed at the beginning and completion of a four-year veterinary medicine program. Eighty-six students (74.4% female) were included in this Canadian study over a six-year period. Thirty-one participants (36.1%) were rural students. Overall, students' attitudes toward the rural lifestyle, rural work-life balance, and inter-professional teamwork in rural veterinary practice all significantly decreased (p<.001) over the course of the program. As compared to urban students, rural students had significantly higher rural lifestyle scores at both the beginning (p<.001) and end (p<.01) of the veterinary medicine program. A less positive attitude toward living and working in a rural environment could influence students to exclude rural veterinary practice as a career choice. Rural clinical experiences designed to sustain or increase veterinary student interest in rural practice may not be sufficient to support positive rural attitudes. Given the demand for rural veterinary services in developed countries, the implications of this study may extend beyond Canada.

Beyond bricks and mortar: a rural network approach to preclinical medical education.

BACKGROUND: Countries with expansive rural regions often experience an unequal distribution of physicians between rural and urban communities. A growing body of evidence suggests that the exposure to positive rural learning experiences has an influence on a physician's choice of practice location. Capitalizing on this observation, many medical schools have developed approaches that integrate rural exposure into their curricula during clerkship. It is postulated that a preclinical rural exposure may also be effective. However, to proceed further in development, accreditation requirements must be considered. In this investigation, academic equivalence between a preclinical rural community based teaching method and the established education model was assessed. METHOD: Two separate preclinical courses from the University of Calgary's three year Undergraduate Medical program were taught at two different rural sites in 2010 (11 students) and 2012 (12 students). The same academic content was delivered in the pilot sites as in the main teaching centre. To ensure consistency of teaching skills, faculty development was provided at each pilot site. Academic equivalence between the rural based learners and a matched cohort at the main University of Calgary site was determined using course examination scores, and the quality of the experience was evaluated through learner feedback. RESULTS: In both pilot courses there was no significant difference between examination scores of the rural distributed learners and the learners at the main University of Calgary site (p > 0.05). Feedback from the participating students demonstrated that the preceptors were very positively rated and, relative to the main site, the small group learning environment appeared to provide strengthened social support. CONCLUSION: These results suggest that community distributed education in pre-clerkship may offer academically equivalent training to existing traditional medical school curricula while also providing learners with positive rural social learning environments. The approach described may offer the potential to increase exposure to rural practice without the cost of constructing additional physical learning sites.

How do medical students form impressions of the effectiveness of classroom teachers?

CONTEXT: Teaching effectiveness ratings (TERs) are used to provide feedback to teachers on their performance and to guide decisions on academic promotion. However, exactly how raters make decisions on teaching effectiveness is unclear. OBJECTIVES: The objectives of this study were to identify variables that medical students appraise when rating the effectiveness of a classroom teacher, and to explore whether the relationships among these variables and TERs are modified by the physical attractiveness of the teacher. METHODS: We asked 48 Year 1 medical students to listen to 2-minute audio clips of 10 teachers and to describe their impressions of these teachers and rate their teaching effectiveness. During each clip, we displayed either an attractive or an unattractive photograph of an unrelated third party. We used qualitative analysis followed by factor analysis to identify the principal components of teaching effectiveness, and multiple linear regression to study the associations among these components, type of photograph displayed, and TER. RESULTS: We identified two principal components of teaching effectiveness: charisma and intellect. There was no association between rating of intellect and TER. Rating of charisma and the display of an attractive photograph were both positively associated with TER and a significant interaction between these two variables was apparent (p < 0.001). The regression coefficient for the association between charisma and TER was 0.26 (95% confidence interval [CI] 0.10-0.41) when an attractive picture was displayed and 0.83 (95% CI 0.66-1.00) when an unattractive picture was displayed (p < 0.001). CONCLUSIONS: When medical students rate classroom teachers, they consider the degree to which the teacher is charismatic, although the relationship between this attribute and TER appears to be modified by the perceived physical attractiveness of the teacher. Further studies are needed to identify other variables that may influence subjective ratings of teaching effectiveness and to evaluate alternative strategies for rating teaching effectiveness.

Filling in the gaps of clerkship with a comprehensive clinical skills curriculum.

Although the clinical clerkship model is based upon sound pedagogy, including theories of social learning and situated learning, studies evaluating clinical performance of residents suggests that this model may not fully meet the learning needs of students. Here our objective was to design a curriculum to bridge the learning gaps of the existing clerkship model and then evaluate the impact of this on performance on clerkship summative evaluations. We followed Kern's framework to design our curriculum and then compared performance on the clerkship objective structured clinical examination (OSCE), all summative clerkship multiple choice question (MCQ) examinations, and the Medical Council of Canada Qualifying Examination (MCCQE) Part 1 before and after the introduction of our curriculum. In the 2 years following the introduction of our clinical skills curriculum the mean score on the clerkship OSCE was significantly higher than in the 2 years prior to our curriculum [67.12 (5.3) vs. 62.44 (4.93), p < 0.001, d = 0.91]. With the exception of the surgical clerkship MCQ, performance on all clerkship summative MCQ examinations and MCCQE Part 1 was significantly higher following the introduction of our curriculum. In this study we found a significant improvement in the performance on clerks on summative evaluations of knowledge and clinical skills following the introduction of our clinical skills curriculum. Given the unpredictable nature of clinical rotations, the clerkship will always be a risk of failing to deliver the intended curriculum-so medical schools should continue to explore and evaluate ways of changing the delivery of clerkship training to improve learning outcomes.

Exposure and attitudes toward interprofessional teams: a three-year prospective study of longitudinal integrated clerkship versus rotation-based clerkship students.

This study explored exposure to, and attitudes toward, interprofessional (IP) teams between third-year longitudinal integrated clerkship (LIC) and traditional rotation-based clerkship (RBC) students at the University of Calgary medical school. Students completed a survey pre-post 32-week LIC or 6-week rural, regional or urban RBC family medicine rotations. Pre and post rotation surveys were completed by 213 (48%) students (LIC = 33/34; rural = 76/152; regional = 24/46; urban = 80/208). More LIC students (76%) reported participating on six or more IP teams than RBC students (rural = 38%; regional = 25%; urban = 21%). At pre rotation, the mean attitude to IP teams score of LIC and rural RBC students was high and did not differ. At post rotation, the mean attitude score of LIC students was significantly greater than the mean reported by rural RBC students. Only LIC students reported a significant pre-post rotation increase in attitude. Exposure to IP teams, possibly facilitated by a longer duration of rotation, appears to be an important factor in affecting attitude to IP teams.

Comparing the performance in family medicine residencies of graduates from longitudinal integrated clerkships and rotation-based clerkships.

PURPOSE: In 2008, the University of Calgary implemented a longitudinal integrated clerkship (LIC) called the Rural Integrated Community Clerkship (RICC), which places students in a rural community for 32 weeks. Research indicates that LIC students perform academically as well as or better than students completing rotation-based clerkships (RBCs). However, little is known about how LIC graduates perform in residency. This study compared residency program director ratings of RICC and RBC graduates. METHOD: The performance of RICC and RBC graduates (2009-2011) was assessed using a rating form mailed to family medicine residency program directors at the end of graduates' first postgraduate year. Because of sample size and confounding effects of discipline, only the performance of graduates training in family medicine was examined. Data were analyzed using factor analysis, ANOVA, and chi-square. RESULTS: Three hundred sixteen of 399 (80.8%) rating forms were returned. The instrument contained two factors (clinical acumen and human sensitivity) of acceptable reliability (≥ 0.90) plus an overall rating of performance. Of 124 (31.7%) students who matched to family medicine, 101 (81.5%) rating forms (RICC = 22/25; RBC = 79/99) were returned. Program directors rated the performance of RICC graduates to be at least equivalent to their RBC peers on both dimensions. On overall performance, 16/22 (72.7%) RICC graduates and 43/79 (54.4%) RBC graduates were rated as "stronger" or "much stronger" than most residents in the program, P = .30. CONCLUSIONS: The performance of RICC graduates was at least equivalent to the performance of their RBC peers.

Academic performance of longitudinal integrated clerkship versus rotation-based clerkship students: a matched-cohort study.

PURPOSE: Prior studies suggest that students on a longitudinal integrated clerkship (LIC) have comparable academic performance to those on a rotation-based clerkship (RBC); however, most of these studies did not adjust for preclerkship academic performance. The objective of this study was to compare the academic performance of LIC and RBC students matched on prior academic performance over a three-year period. METHOD: Each LIC student in the University of Calgary classes of 2009, 2010, and 2011 (n = 34) was matched with four RBC students (n = 136) of similar prior academic performance. Knowledge and clinical skills performance between the streams was compared. Knowledge was evaluated by internal summative examinations and the Medical Council of Canada Part 1 licensing exam. Clinical skills were evaluated via in-training evaluation report (ITERs) and performance on the clerkship objective structured clinical examination (OSCE). Meta-analysis was used to compare knowledge evaluations and clinical performance for all core clerkship disciplines, and pooled effect sizes from the fixed-effect models were reported. RESULTS: Meta-analyses showed no statistically significant heterogeneity. There were no differences between LIC and RBC students on knowledge evaluations (pooled effect size 0.019; 95% confidence interval [-0.155, 0.152], P = .8), ITERs (pooled effect size -0.015 [-0.157, 0.127], P = .8), or mean OSCE ratings (67.9 [SD = 4.6] versus 68.6 [SD = 5.8], P = .5). CONCLUSIONS: After matching on prior academic performance, LIC and RBC students at one school had comparable performance on summative evaluations of knowledge, clinical performance, and clinical skills over three years.

Predicting performance on the Medical Council of Canada Qualifying Exam Part II.

BACKGROUND: Being able to predict which residents will likely be unsuccessful on high-stakes exams would allow residency programs to provide early intervention. PURPOSE: To determine whether measures of clinical performance in clerkship (in-training evaluation reports) and first year of residency (program director ratings) predict pass-fail performance on the Medical Council of Canada Qualifying Exam Part II (MCCQE Part II). METHODS: Residency program directors assessed the performance of our medical school graduates (Classes 2004-2007) at the end of the 1st postgraduate year. We subsequently collected clerkship in-training evaluation reports for these graduates. Using a neutral third party and unique codes, an anonymous dataset containing clerkship, residency, and MCCQE Part II performance scores was created for our use. Data were analyzed using descriptive statistics, correlations, receiver operating characteristics, and the Youdin index. Regression was also performed to further study the relationship among the variables. RESULTS: Complete data were available for 78.6% of the graduates. Of these participants, 94% passed the licensing exam on their first attempt. Receiver operating characteristics revealed that the area under the curve for clerkship in-training evaluation reports was 0.67 (p<.05) and 0.66 (p<.05) for residency program directors assessments. Corresponding Youdin indices for in-training evaluation reports and residency program director assessments were 0.30 and 0.23, respectively. CONCLUSIONS: Although clerkship in-training evaluation reports and residency program director ratings are significant predictors of pass-fail performance on the MCCQE Part II, the effectiveness of each one to predict pass-fail performance was relatively small. Reasons for these findings are discussed.

Perceived preparedness for family practice: does rural background matter?

INTRODUCTION: Rural background and the ability to adjust to rural practice are strong predictors of recruitment and retention of rural physicians. The degree to which rural background and being prepared for practice interrelate may provide insight into efforts aimed at increasing the supply of rural physicians. The purpose of this study was to examine the association between family medicine graduates' rural or urban background and their self-reported preparedness for practice. METHODS: This was a retrospective, cross-sectional survey of family medicine graduates who completed the 2-year family medicine residency program at the University of Alberta or University of Calgary from 2001 to 2005. Self-rated preparedness was examined on a 4-point Likert scale for 18 elements of clinical family practice, 8 interdisciplinary issues, 10 practice management issues and 8 nonclinical aspects of family practice. Rural background was defined as having been brought up mainly in a rural community (population < 25 000), and urban background was defined as having been brought up mainly in an urban community (population ≥ 25 000). RESULTS: A significantly greater proportion of rural-than urban-background graduates felt prepared for 3 nonclinical aspects of rural practice: time demands of rural practice (95.0% v. 79.3%, p = 0.03), understanding rural culture (92.5% v. 70.2%, p = 0.005) and small-community living (92.5% v. 70.2%, p = 0.003). CONCLUSION: Rural background was associated with physicians feeling prepared for the nonclinical and cultural aspects of rural family practice, which suggests that focused rural exposure facilitates an understanding of rural culture. Urban-background physicians were reportedly less prepared for the nonclinical aspects of rural practice. Increased exposure of urban-background residents to the cultural aspects of rural practice may improve recruitment and retention of rural family physicians.

Rater variables associated with ITER ratings.

Advocates of holistic assessment consider the ITER a more authentic way to assess performance. But this assessment format is subjective and, therefore, susceptible to rater bias. Here our objective was to study the association between rater variables and ITER ratings. In this observational study our participants were clerks at the University of Calgary and preceptors who completed online ITERs between February 2008 and July 2009. Our outcome variable was global rating on the ITER (rated 1-5), and we used a generalized estimating equation model to identify variables associated with this rating. Students were rated "above expected level" or "outstanding" on 66.4 % of 1050 online ITERs completed during the study period. Two rater variables attenuated ITER ratings: the log transformed time taken to complete the ITER [ß = -0.06, 95 % confidence interval (-0.10, -0.02), p = 0.002], and the number of ITERs that a preceptor completed over the time period of the study [ß = -0.008 (-0.02, -0.001), p = 0.02]. In this study we found evidence of leniency bias that resulted in two thirds of students being rated above expected level of performance. This leniency bias appeared to be attenuated by delay in ITER completion, and was also blunted in preceptors who rated more students. As all biases threaten the internal validity of the assessment process, further research is needed to confirm these and other sources of rater bias in ITER ratings, and to explore ways of limiting their impact.

Rural physicians' skills enrichment program: a cohort control study of retention in Alberta.

OBJECTIVE: The Rural Physician Action Plan of Alberta introduced an enrichment program in 2001 to improve physician access to skills training. The objective of this study was to evaluate this program and measure retention compared with matched controls over 5 years. DESIGN: Longitudinal, matched, case control study and program evaluation. SETTING: Rural communities in Alberta, Canada. PARTICIPANTS: Rural physicians. INTERVENTIONS: Thirty-one rural physicians self-selected their personal skills training program and listed three goals they wished to attain. They were matched by age, specialty, years in practice and size of community with rural physicians who did not participate in a skills training or upgrading program. MAIN OUTCOME MEASURES: Goal attainment for subject physicians, use of skills at 5 years and comparison of rural retention of physicians at 5 years. RESULTS: Thirty-two of thirty-five physicians classified their goal attainment to be as expected or greater, and all were using their new skills at 5 years. Of the matched physicians, 29 training participants remained in rural practice at 5 years compared with only 22 of 29 matched control: relative risk 1.31, confidence interval 1.06-1.62 P < 0.05. CONCLUSIONS: The enrichment program provides focused, valued skills training for rural physicians and long-term benefits to rural communities.