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Background: Globalization results in a rapidly diversifying population, increased inequities, and more complex health problems affecting populations. This forces medical schools to integrate global health (GH) into the training of health-care professionals from curriculum development to practical learning activities, here and abroad.Approach: The approach aims at enriching existing programs in GH competencies in an interdisciplinary context. The goal is to ensure that all health-science students develop a certain level of GH competency. The main actions are the mobilization of key stakeholders, the development of a competency framework (CF) to perform gap analysis, tool formalization, and monitoring and evaluation activities. Subsequent to scoping review and stakeholder consultations, ten principles are identified and used to guide the enrichment process.Results: Actual outputs cover a broad scope, from key decision-makers’ support and endorsement to the formalization of tools and the consolidation and creation of activities such as service-learning activities, rotations among underserved populations, and training for international rotations.Conclusion: While this unique approach is proving to be a major challenge, the preliminary results are well worth the effort. The project’s tangible impacts on health-sciences teaching, the GH competence of graduates, and care delivery are topics of interest for future investigation.

> I do not know where my road is taking me, but I walk better when my hand holds yours. > > — Alfred de Musset “Lie beside me. Hold my hand.” Nicole’s words during her last days. She was 60 and had been my wife for 38 years. The disease plagued her for almost 10 years. Mutilating surgery

Medical examinations translated into two or more languages may discriminate against one or more of the linguistic groups involved if the quality of the translations is poor or if the “medical cultures”; of the different linguistic groups are not identical. The most striking aspect of a literature review of the subject is the paucity of published reports. Over the past 3 years, the authors have gained considerable experience in translating large‐scale objective structured clinical examinations into French and English. Analysis of the examination results is described and leads to the conclusion that the translation does not discriminate against either linguistic group. The translation process developed for these examinations is presented, and hypotheses to explain the scarcity of literature on the subject are developed.

INTRODUCTION An understanding of the contextual, professional, and personal factors that affect choice of practice location for physicians is needed to support successful strategies in addressing geographic maldistribution of physicians. This study compared two categories of predictors of family practice location in non-metropolitan areas among undergraduate medical students: individual characteristics (nature), and the rural program component of their training program (nurture). The study aimed to identify factors that predict the location of practice 2 years post-residency training and determine the predictive value of combining nature and nurture variables using administrative data from two undergraduate medical education programs. METHODS Databases were developed from available administrative sources for a retrospective analysis of two undergraduate medical education programs in Canada: Universite de Sherbrooke (UdeS) and University of British Columbia (UBC). Both schools have a strong mandate to evaluate the impact of their programs on physician distribution. The dependent variable was location of practice 2 years after completing postgraduate training in family medicine. Independent variables included individual and program characteristics. Separate analyses were conducted for each program using multiple logistic regression. RESULTS The nature and nurture variables considered in the models explained only 21% to 27% of the variance in the eventual location of practice of family physician graduates. For UdeS, having an address in a rural/small-town environment at application to medical school (OR=2.61, 95% CI: 1.24-6.06) and for UBC, location of high school in a rural/small town (OR=4.03, 95% CI: 1.05-15.41), both increased the chances of practicing in a non-metropolitan area. For UdeS the nurture variable (ie length of clerkship in a non-metropolitan area) was the most significant predictor (OR=1.14, 95% CI: 1.067-1.22). For both medical schools, adding a single nurture variable to the model using only nature variables significantly increased the amount of variation accounted for in predicting location of practice in non-metropolitan areas. CONCLUSIONS Aspects of graduates' rural background increase the chances of practicing in a non-metropolitan area. A third-year clerkship experience in a rural area may increase the chances of non-metropolitan practice. Although the total variation predicted by both nature and nurture variables in this study was small, adding a nurture variable significantly improves the prediction of individuals who will practice in a non-metropolitan area. The fact that total variation predicted was small is likely to be due to the limitations of the administrative databases used. Different strategies are being implemented in each university to improve the quality of existing administrative databases, as well as to collect relevant data about intent-to-practice, training characteristics, and the attitudes, beliefs and backgrounds of students.

ContextStandards for licensure are designed to provide assurance to the public of a physician's competence to practice. However, there has been little assessment of the relationship between examination scores and subsequent practice performance.ObjectiveTo determine if there is a sustained relationship between certification examination scores and practice performance and if licensing examinations taken at the end of medical school are predictive of future practice in primary care.Design, Setting, and ParticipantsA total of 912 family physicians, who passed the Quebec family medicine certification examination (QLEX) between 1990 and 1993 and entered practice. Linked databases were used to assess physicians' practice performance for 3.4 million patients in the universal health care system in Quebec, Canada. Patients were seen during the follow-up period for the first 4 years (1993 cohort of physicians) to 7 years (1990 cohort of physicians) of practice from July 1 of the certification examination to December 31, 1996.Main Outcome MeasuresMammography screening rate, continuity of care index, disease-specific and symptom-relief prescribing rate, contraindicated prescribing rate, and consultation rate.ResultsPhysicians achieving higher scores on both examinations had higher rates (rate increase per SD increase in score per 1000 persons per year) of mammography screening (β for QLEX, 16.8 [95% confidence interval {CI}, 8.7-24.9]; β for Medical Council of Canada Qualifying Examination [MCCQE], 17.4 [95% CI, 10.6-24.1]) and consultation (β for QLEX, 4.9 [95% CI, 2.1-7.8]; β for MCCQE, 2.9 [95% CI, 0.4-5.4]). Higher subscores in diagnosis were predictive of higher rates in the difference between disease-specific and symptom-relief prescribing (β for QLEX, 3.9 [95% CI, 0.9-7.0]; β for MCCQE, 3.8 [95% CI, 0.3-7.3]). Higher scores of drug knowledge were predictive of a lower rate (relative risk per SD increase in score) of contraindicated prescribing for MCCQE (relative risk, 0.88; 95% CI, 0.77-1.00). Relationships between examination scores and practice performance were sustained through the first 4 to 7 years in practice.ConclusionScores achieved on certification examinations and licensure examinations taken at the end of medical school show a sustained relationship, over 4 to 7 years, with indices of preventive care and acute and chronic disease management in primary care practice.

Objective Structured Clinical Examination (OSCE) is now generally considered as the new gold standard for evaluating clinical competence. The objective of this study was to assess the feasibility of OSCE in evaluating urology residents.20 urology residents rotated through a circuit of five standardized patient-based OSCE stations of 10 min duration. The selection of problems was based on educational objectives of urology residency programs. Written questionnaires based on Likert-type scales were used to measure OSCE feasibility. The mean score was arbitrarily used as a passing score. Student t test was only used to compare the performance between junior and senior residents.Senior residents performed globally better, but without significant differences (51.3+/-7.8 vs. 45.03+/-5.1, p0.05). Senior resident scores regarding outpatient problems were significantly higher (p = 0.04), more senior residents reached the passing score (75 vs. 16% junior residents). All the participants agreed that the clinical situations were realistic and that the simulated patients were believable. Most participants agreed that the sampling of cases were representative of urology practice.This is the first reported OSCE applied to urology residency. The results of this pilot study support the feasibility of an OSCE in assessing the performance of urology residents. Our data raises questions regarding the training of outpatient consultation skills to residents. This experiment warrants further series to explore the study's psychometrics features.

Context.—Clinical competence is a determinant of the quality of care delivered, and may be associated with use of health care resources by primary care physicians. Clinical competence is assumed to be assessed by licensing examinations, yet there is a paucity of information on whether scores achieved predict subsequent practice.Objective.—To determine if licensing examination scores were associated with selected aspects of quality of care and resource use in initial primary care practice.Design.—Prospective cohort study of recently licensed family physicians, followed up for the first 18 months of practice.Setting.—The Quebec health care system.Participants.—A total of 614 family physicians who passed the licensing examination between 1991 and 1993 and entered fee-for-service practice in Quebec.Main Outcome Measures.—All patients seen by physicians were identified by the universal health insurance board and all health services provided to these patients were retrieved for the 18 months prior to (baseline) and after (follow-up) the physicians' entry into practice. Medical service and prescription claims files were used to measure rates of resource use (specialty consultation, symptom-relief prescribing compared with disease-specific prescribing) and quality of care (inappropriate prescribing, mammography screening). Baseline data were used to adjust for differences in practice population.Results.—Study physicians saw a total of 1116389 patients, of whom 113535 (10.2%) were elderly and 83391 (7.5%) were women aged 50 to 69 years. Physicians with higher licensing examination scores referred more of their patients for consultation (3.8/1000 patients per SD increase in score; 95% confidence interval [CI], 1.2-7.0; P=.005), prescribed to elderly patients fewer inappropriate medications (−2.7/1000 patients per SD increase in score; 95% CI, −4.8 to −0.7; P =.009) and more disease-specific medications relative to symptom-relief medications (3.9/1000 patients per SD increase in score; 95% CI, 0.3 to 7.4; P=.03), and referred more women aged 50 to 69 years (6.6/1000 patients per SD increase in score; 95% CI, 1.2-11.9; P=.02) for mammography screening. If patients of physicians with the lowest scores had experienced the same rates of consultation, prescribing, and screening as patients of physicians with the highest scores, an additional 3027 patients would have been referred, 179 fewer elderly patients would have been prescribed symptom-relief medication, 912 more elderly patients would have been prescribed disease-specific medication, 189 fewer patients would have received inappropriate medication, and 121 more women would have received mammography screening.Conclusions.—Licensing examination scores are significant predictors of consultation, prescribing, and mammography screening rates in initial primary care practice.

Female candidates have been shown to repeatedly outperform male candidates in examinations measuring their medical competence. This study explored differences in the results of both groups on the 1993, 1994 and 1995 Quebec licensing examinations which used two SP-based instruments and one paper and pencil instrument. ANOVA and ANCOVA analyses confirmed that female candidates obtained higher results on all instruments year after year, and that these results were not biased by the content of the examination.

The large scale standardized patient-based objective structured clinical examination used in Quebec licensing examination was held for the first time in 1990 and was the 1st OSCE in the world used for high-stakes purposes such as licensure. As of June 1996, 13 examination sessions have been implemented and more than 1500 candidates assessed. Major changes have been implemented through the years in order to improve the examination. The length of the cases has been progressively increased from 7 minutes duration to 7, 10, 14 or 20 minutes duration according to the complexity of the clinical situations. More weight has been given to the assessment of integrative problem solving skills such as diagnosis and treatment. A multiple key feature approach to weighting the assessment items in the cases is progressively used. Sophisticated psychometric analysis of the results, that confirmed the quality of the examination, have been implemented.

To look at how well residency directors in family medicine predict the performances of their candidates on the Quebec Licensing Examination (QLEx) for family physicians.The four family medicine program directors in Quebec were asked in the spring of 1992 to identify the ten residents from their own programs who would get the highest marks on the QLEx and the ten who would get the lowest marks. From the results of these candidates, and those of the intermediate groups defined by default, the prediction abilities of the program directors were assessed.Descriptive statistics showed that the program directors had difficulties discriminating among the different groups and tended to collapse the predicted scores toward the total mean. Analysis-of-variance studies confirmed the absence of difference between the predicted weak and intermediate groups as well as between the predicted intermediate and strong groups for each program and for each QLEx component. Regression analysis as well as eta 2 studies showed that the program directors' prediction abilities were low for all components and represented less than 25% of the explained variance of the QLEx scores.The residency directors did not accurately categorize their residents' performances on the QLEx. Both the evaluations of program directors and terminal examination results are complementary approaches to clinical competence assessment and should be used for licensure.

Objective To assess whether the transition from a traditional curriculum to a community oriented problem based learning curriculum at Sherbrooke University is associated with the expected improvements in preventive care and continuity of care without a decline in diagnosis and management of disease. Design Historical cohort comparison study. Setting Sherbrooke University and three traditional medical schools in Quebec, Canada. Participants 751 doctors from four graduation cohorts (1988-91); three before the transition to community based problem based learning (n = 600) and one after the transition (n = 151). Outcome measures Annual performance in preventive care (mammography screening rate), continuity of care, diagnosis (difference in prescribing rates for specific diseases and relief of symptoms), and management (prescribing rate for contraindicated drugs) assessed using provincial health databases for the first 4-7 years of practice. Results After transition to a community oriented problem based learning curriculum, graduates of Sherbrooke University showed a statistically significant improvement in mammography screening rates (55 more women screened per 1000, 95% confidence interval 10.6 to 99.3) and continuity of care (3.3% more visits coordinated by the doctor, 0.9% to 5.8%) compared with graduates of a traditional medical curriculum. Indicators of diagnostic and management performance did not show the hypothesised decline. Sherbrooke graduates showed a significant fourfold increase in disease specific prescribing rates compared with prescribing for symptom relief after the transition. Conclusion Transition to a community oriented problem based learning curriculum was associated with significant improvements in preventive care and continuity of care and an improvement in indicators of diagnostic performance.