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Background and Objectives: The global shift towards competency-based medical education (CBME) has led to the development of national guidelines for CBME implementation (CBME Guides). The characteristics of CBME Guides from CBME-developed countries were analysed to inform the revision process for the CBME Guide in Japan, a CBME-developing country., Methods: Document analysis of CBME Guides from Canada, Singapore, the Netherlands, the United Kingdom, and the United States was conducted by six Japanese medical education experts. The process of analysing the CBME Guides was also reviewed., Results: While the CBME Guides contain many commonalities in structure and content, there is variation in terminology and forms of expression. The characteristics vary according to national systems, culture, and customs. The content of the Guides may have changed depending on the publication date, in line with changes in medical technology, medical needs, and advances in the understanding of CBME., Conclusions: Analysing CBME Guides from CBME-developed countries may lead to more meaningful revisions to a CBME-developing country's guide, enabling it to be better aligned with the local, social, cultural, and historical context of the country now and in the future.

Introduction: Addressing systemic bias in medical school assessment is an urgent task for medical education. This paper outlines recommendations on topic areas for further research on systemic bias, developed from a workshop discussion at the 2023 annual meeting of the Society of Directors of Research in Medical Education., Materials and Methods: During the workshop, directors engaged in small-group discussions on guidelines to address bias in assessment practices following a proposed categorization of 'Do's,' 'Don'ts,' and 'Don't knows' and listed their insights using anonymous sticky notes, which were shared and discussed with the larger group of participants. The authors performed a content analysis of the notes through deductive and inductive coding. We reviewed and discussed our analysis to reach consensus., Results: The workshop included 31 participants from 28 institutions across the US and Canada, generating 51 unique notes. Participants identified 23 research areas in need of further study. The inductive analysis of proposed research areas revealed four main topics: 1) The role of interventions, including pre-medical academic interventions, medical-education interventions, assessment approaches, and wellness interventions; 2) Professional development, including the definition and assessment of professionalism and professional identity formation; 3) Context, including patient care and systemic influences; and 4) Research approaches., Discussion: While limited to data from a single workshop, the results offered perspectives about areas for further research shared by a group of directors of medical education research units from diverse backgrounds. The workshop produced valuable insights into the need for more evidence-based interventions that promote more equitable assessment practices grounded in real-world situations and that attenuate the effects of bias.

Background: The Objective Structured Clinical Examination (OSCE) is a commonly used tool internationally to assess clinical competency. Physical therapy (PT) licensure processes vary internationally. The OSCE is the tool used in Canada to assess clinical competency for PT graduates seeking licensure. Previous studies that examined the measurement properties of OSCEs present contradictory results., Objectives: The first objective was to investigate the reliability and validity of OSCEs when administered to PTs during their education or as part of a licensure process. The second objective was to conduct a structured review to report PT educational and licensing components and policies in 17 countries with well-developed PT regulation systems., Methods: An electronic search was performed in four databases from inception to 31st March 2021 to identify relevant articles. Two reviewers performed the critical appraisal of the included studies using a validated quality assessment tool. We deployed a random effects meta-analysis on reliability and validity estimates of OSCEs and examined sources of heterogeneity with univariate meta-regressions. We searched websites of professional regulatory bodies and associations for data on educational and licencing components and policies. Educational and licensing components across countries were synthesized descriptively., Results: A pooled estimate of Cronbach's alpha of 0.55, (95% CI: 0.41, 0.67) was determined for OSCEs. The pooled estimate of Intraclass Correlation Coefficient (ICC) between assessors was 0.77 (95% CI: 0.70, 0.83). The pooled estimate of Pearson Correlation between multiple OSCE stations' scores was 0.27 (95% CI: 0.15, 0.39); and between each station score and the total score was 0.71 (95% CI: 0.61, 0.79). The pooled estimates for kappa Coefficients were 0.75 (95% CI: 0.58, 0.86) and 0.84, (95% CI: 0.72, 0.91) for intra-rater and inter-rater reliability of the standardised patient respectively. From the 17 included countries, Canada (excluding Quebec) was the only country that required both a clinical and written competency exam following graduation from an accredited PT program. Two countries (USA, UAE) required a written competency exam. The remaining 14 countries did not require an additional competency examination after completion of degree requirements from an accredited program., Conclusions: We found weak evidence that OSCE examinations items are internally consistent when used to assess PTs. Canada (excluding Quebec) is the only country out of 17 implementing a national clinical competency examination for their PT graduates to achieve licensure after completing professional degree requirements., Competing Interests: The authors have declared that no competing interests exist.

Background: Medical education affects learner well-being. We explored the breadth and depth of interventions to improve the well-being of medical learners in Canada., Methods: We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to July 11, 2020, using the Arksey-O'Malley, 5-stage, scoping review method. We included interventions to improve well-being across 5 wellness domains (i.e., social, mental, physical, intellectual, occupational) for medical learners in Canada, grouped as undergraduate or graduate nonmedical (i.e., health sciences) students, undergraduate medical students or postgraduate medical students (i.e., residents). We categorized interventions as targeting the individual (learner), program (i.e., in which learners are enrolled) or system (i.e., higher education or health care) levels., Results: Of 1753 studies identified, we included 65 interventions that aimed to improve well-being in 10 202 medical learners, published from 1972 through 2020; 52 (80%) were uncontrolled trials. The median year for intervention implementation was 2010 (range 1971-2018) and the median length was 3 months (range 1 h-48 mo). Most ( n = 34, 52%) interventions were implemented with undergraduate medical students. Two interventions included only undergraduate, nonmedical students; none included graduate nonmedical students. Most studies ( n = 51, 78%) targeted intellectual well-being, followed by occupational ( n = 32, 49%) and social ( n = 17, 26%) well-being. Among 19 interventions implemented for individuals, 14 (74%) were for medical students; of the 27 program-level interventions, 17 (63%) were for resident physicians. Most ( n = 58, 89%) interventions reported positive well-being outcomes., Interpretation: Many Canadian medical schools address intellectual, occupational and social well-being by targeting interventions at medical learners. Important emphasis on the mental and physical well-being of medical learners in Canada warrants further exploration., Competing Interests: Competing interests: None declared., (© 2021 CMA Joule Inc. or its licensors.)

Objectives: The day-to-day management of diabetes is often the responsibility of resident physicians in teaching hospitals, yet studies have consistently shown that learners lack confidence and knowledge of inpatient insulin titration. We sought to elucidate factors that influence inpatient management of diabetes by medical learners. We predicted that there would be conscious and unconscious variables at play, and we sought to determine the process by which learners arrived at insulin titration decisions., Methods: We administered a survey using a hypothetical case based on script concordance testing in 88 medical students and residents at the University of Calgary. We used multilevel, mixed-effects linear regression and random-effects meta-analysis to compare clerks' and residents' insulin prescribing, confidence in prescribing decisions and concordance with endocrinologists., Results: Residents had higher confidence than clerks, yet were less concordant with the insulin decisions of staff endocrinologists. Both residents and clerks prescribed more insulin when the reported blood glucose was higher, or the patient had positive ketones and prescribed less insulin when the patient had hypoglycemic unawareness. Residents prescribed a higher dose of insulin when the charge nurse reported the result compared with a student nurse, but this variable did not significantly impact prescribing by clerks., Conclusions: We propose a model in which learner factors (knowledge, confidence, experience), patient variables and perceived expectations influence insulin titration decisions via analytical and heuristic processes. We propose that educational interventions designed to improve inpatient glycemic control must, therefore, address both knowledge and systems factors., (Copyright © 2020 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: Simone Vigod reports receiving royalties for authorship of materials related to depression and pregnancy, from UpToDate, Inc. No other competing interests were declared.

Both in Canada and globally, medical schools are prioritizing diversity in medical education. The ensuing development of innovative approaches to augmenting the representation, comfort, and success of students from under-represented groups has been increasing. Curricula have also expanded to better prepare graduates for the realities of effectively meeting the needs of a diverse patient population. Leadership has however, not kept up with this progress. Evidence shows that diverse leadership teams develop innovative solutions to complex problems, recruit and retain the best talent, and remain relevant to the communities they serve. Our international conference workshop included a literature review on the current state of diversity in medical education and in leadership for medical educators, and case-based models of lived experiences to initiate conversations in three different facets of diversity to stimulate reflection, engagement and discussion. The oft-forgotten side of the conversation in conference offerings, the audience's perspective, was purposefully included in planning the workshop and presenters adhered to this principle throughout the session. Participants recognized the importance of addressing diversity with leadership in medical education. Themes included the need for communication training, cultural education, sharing these data more broadly with faculty in medical education and continuing these conversations. A final theme "we will never represent all minorities", led us to a conclusion that a culture of inclusivity and not diversity would be required to successfully meet this challenge., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 LeBlanc et al.)

In North America, the psychiatric workforce while relatively large, remains insufficient for the population needs. Specialist training opportunities in psychiatry continues to grow, reflected in both increased recruitment and competitiveness. Furthermore, the iterative process of curriculum development and standardisation of training encourages greater educational consistency. There is an ongoing growth in subspecialty training opportunities, however access varies across centres and curriculum gaps remain. The diverse demographic characteristics and requirements of populations also play a role in educational needs, such as youth mental health, tele-psychiatry, cultural, rural and addictions psychiatry. Advances in science such as genetics, and the use of technologies and digital media also invite innovative approaches to knowledge acquisition. Overall, training needs to be matched by sufficient numbers of experienced and skilful trainers, mentorship and leadership in psychiatry with awareness of physician wellbeing and the risks of burnout. In the USA and Canada, the growing prospect of fellowships in leadership and administration lay important foundations for the growth of psychiatry, driven by high quality education for the mental health professionals and leaders of tomorrow.

In 2008, a Canadian strategy called the "Educating Future Physicians in Palliative and End-of-Life Care" (EFPPEC) project published national medical undergraduate competencies for palliative and end-of-life care. Since that time, there have been several changes in the practice environment. To formally incorporate these changes and also update the competencies for EFPPEC, an EFPPEC update project team was established in 2017. The EFPPEC update document in English was finalized in June 2018, and subsequent minor amendments to the French version were completed in January 2019. This report describes the process and also shares the new updated EFPPEC competencies with the wider palliative care community.

North American naturopathic medicine is a distinct form of practice that is woven into the larger fabric of integrative medicine; in a number of US states and Canadian provinces, naturopathic doctors enjoy a wide scope of practice, including the ability to make diagnoses, order tests, use medical technology, write prescription drugs, and perform minor surgeries. However, the basic premise of naturopathic medicine and its guiding principles-considering the whole person and supporting healthy lifestyle behaviors-is the unifying approach in clinical practice. In the 1970s, homeopathy-considered in many circles to be a hypothesis-driven, fringe form of alternative medicine-became embedded into the training and practice of North American naturopathic doctors. Since the earliest days of its theory (circa 1800), homeopathy has escaped, and continues to escape, biological plausibility; however, the persistence of this modality (and the insistence by both its consumers and practitioners that it provides benefit) speaks to the role of expectations, beliefs, values, agency, context effects, and the placebo-at-large. It is our contention that the progression of professional naturopathic medicine in the 21st century requires a major transition in how it approaches the subject of homeopathy. We propose that students should be encouraged to critically analyze the tenets of homeopathy, its lesser known history, and the idea of homeopathy as a biomedicine that simply awaits untold chemicophysical mechanisms. Furthermore, the modality of homeopathy should be incorporated into the larger context of placebo studies, narrative medicine, ethics, and psychotherapeutic techniques.

Students of African ancestry often share an experience of being a racialized minority in the context of the educational institution. Late Professor of Anthropology John Ogbu's Cultural-ecological Theory of Academic Disengagement is employed to describe the negative responses encountered by peers in the name of academic achievement. The late Nigerian-American anthropologist John Ogbu described that it is often socially disadvantageous for black youth to prosper academically in formal education. Black students are often seen as betraying their cultural identities by aspiring to academic success and scholastic achievement and are met with repugnance by black peers. The notion of "acting white" is unnecessary, impertinent should be abandoned outright as achievement should have no color., (Copyright © 2017 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Summary: Point of care ultrasonography (POCUS) is revolutionizing care of critically ill patients. However, training in POCUS is extremely variable, with no accepted curriculum or certification process. We aimed to delineate the training experience and use of POCUS among trauma providers across Canada via a secure e-questionnaire sent to members of the Trauma Association of Canada. This commentary discusses our survey results and argues for the standardization of POCUS training and certification in Canada.

Objective: In 2010, Pain Medicine was formally recognized as a subspecialty in Canada by the Royal College of Physicians and Surgeons of Canada, a national organization with oversight of the medical education of specialists in Canada. The first trainees began their training at the Western University, London, Canada in July, 2014. This article traces the process of Pain Medicine's development as a discipline in Canada and outlines its multiple entry routes, 2-year curriculum, and assessment procedures., Design: The application for specialty status was initiated in 2007 with the understanding that while Anesthesiology would be the parent specialty, the curriculum would train clinicians in a multidisciplinary setting. To receive recognition as a Royal College subspecialty, Pain Medicine had to successfully pass through three phases, each stage requiring formal approval by the Committee on Specialties. The multiple entry routes to this 2-year subspecialty program are described in this article as are the objectives of training, the curriculum, assessment of competency and the practice-eligibility route to certification. The process of accreditation of new training programs across Canada is also discussed., Conclusions: The new Pain Medicine training program in Canada will train experts in the prevention, diagnosis, treatment and rehabilitation of the spectrum of acute pain, cancer pain and non-cancer pain problems. These physicians will become leaders in education, research, advocacy and administration of this emerging field., (Wiley Periodicals, Inc.)

The 16th International Ottawa Conference/Canadian Conference on Medical Education (2014) featured a keynote deconstructing the rising discourse of competence-as-reflection in medical education. This paper, an elaborated version of the presentation, is an investigation into the theoretical roots of the diverse forms of reflective practice that are being employed by medical educators. It also raises questions about the degree to which any of these practices is compatible with assessment.

Background: The concept of prognosis dates back to antiquity. Quantum advances in diagnostics and therapeutics have relegated this once highly valued core competency to an almost negligible role in modern medical practice. Medical curricula are devoid of teaching opportunities focused on prognosis. This void is driven by a corresponding relative dearth within physician competency frameworks. This study aims to assess the level of content related to prognosis within CanMEDS (Canadian Medical Education Directives for Specialists), a leading and prototypical physician competency framework., Methods: A quantitative content analysis of CanMEDS competency framework was carried out to measure the extent of this deficiency. Foxit Reader 5.1 (Foxit Corporation), a keyword scanning software, was used to assess the CanMEDS 2005 framework documents of 29 physician specialties and 37 subspecialties across the seven physician roles (medical expert, communicator, collaborator, manager, health advocate, scholar, and professional). The keywords used in the search included prognosis, prognostic, prognosticate, and prognostication., Results: Of the 29 specialties six (20.7%) contained at least one citation of the keyword "prognosis", and one (3.4%) contained one citation of the keyword "prognostic". Of the 37 subspecialties, sixteen (43.2%) contained at least one citation of the keyword "prognosis", and three (8.1%) contained at least one citation of the keyword "prognostic". The terms "prognosticate" and "prognostication" were completely absent from all CanMEDS 2005 documents. Overall, the combined citations for "prognosis" and "prognostic" were linked with the following competency roles: Medical Expert (80.3%), Scholar (11.5%), and Communicator (8.2%)., Conclusions: Given the fundamental and foundational importance of prognosis within medical practice, it is recommended that physicians develop appropriate attitudes, skills and knowledge related to the formulation and communication of prognosis. The deficiencies within CanMEDS, demonstrated by this study, should be addressed in advance of the launch of its updated version in 2015.

Background: Needs assessment should be the starting point for curriculum development. In medical education, expert opinion and consensus methods are commonly employed., Aim: This paper showcases a more practice-grounded needs assessment approach., Methods: A mixed-methods approach, incorporating a national survey, practice audit, and expert consensus, was developed and piloted in thrombosis medicine; Phase 1: National survey of practicing consultants, Phase 2: Practice audit of consult service at a large academic centre and Phase 3: Focus group and modified Delphi techniques vetting Phase 1 and 2 findings., Results: Phase 1 provided information on active curricula, training and practice patterns of consultants, and volume and variety of thrombosis consults. Phase 2's practice audit provided empirical data on the characteristics of thrombosis consults and their associated learning issues. Phase 3 generated consensus on a final curricular topic list and explored issues regarding curriculum delivery and accreditation., Conclusions: This approach offered a means of validating expert and consensus derived curricular content by incorporating a novel practice audit. By using this approach we were able to identify gaps in training programs and barriers to curriculum development. This approach to curriculum development can be applied to other postgraduate programs.

Calls to increase the demographic representativeness of medical classes to better reflect the diversity of society are part of a growing international trend. Despite this, entry into medical school remains highly competitive and exclusive of marginalized groups. To address these questions, we conducted a Foucauldian discourse analysis of 15 publically available policy documents from the websites of Canadian medical education regulatory bodies, using the concepts of "excellence" (institutional or in an applicant), "diversity," and "equity" to frame the analysis. In most documents, there were appeals to broaden definitions of institutional excellence to include concerns for greater social accountability. Equity concerns tended to be represented as needing to be dealt with by people in positions of authority in order to counter a "hidden curriculum." Diversity was represented as an object of value, situated within a discontinuous history. As a rhetorical strategy, documents invoked complex societal shifts to promote change toward a more humanistic medical education system and profession. "Social accountability" was reified as an all-encompassing solution to most issues of representation. Although the policy documents proclaimed rootedness in an ethos of improving the societal responsiveness of the medical profession, our analysis takes a more critical stance towards the discourses identified. On the basis of our research findings, we question whether these calls may contribute to the maintenance of the specific power relations they seek to address. These conclusions lead us to consider the possibility that the discourses represented in the documents might be reframed to take into account issues of power distribution and its productive and reproductive features. A reframing of discourses could potentially generate greater inclusiveness in policy development processes, and afford disadvantaged and marginalized groups more participatory roles in the discussion.

Background: Despite acknowledgement that the Canadian Medical Educational Directives for Specialists (CanMEDS) framework covers the relevant competencies of physicians, many educators and medical professionals struggle to translate the CanMEDS roles into comprehensive training programmes for specific specialties., Aim: To gain insight into the applicability of the CanMEDS framework to guide the design of educational programmes for specific specialties by exploring stakeholders' perceptions of specialty specific competencies and examining differences between those competencies and the CanMEDS framework., Methods: This case study is a sequel to a study among ObsGyn specialists. It explores the perspectives of patients, midwives, nurses, general practitioners, and hospital boards on gynaecological competencies and compares these with the CanMEDS framework., Results: Clinical expertise, reflective practice, collaboration, a holistic view, and involvement in practice management were perceived to be important competencies for gynaecological practice. Although all the competencies were covered by the CanMEDS framework, there were some mismatches between stakeholders' perceptions of the importance of some competencies and their position in the framework., Conclusion: The CanMEDS framework appears to offer relevant building blocks for specialty specific postgraduate training, which should be combined with the results of an exploration of specialty specific competencies to arrive at a postgraduate curriculum that is in alignment with professional practice.

Medical educators aim to train physicians with sound scientific knowledge, expert clinical skills and an ability to work effectively with patients, colleagues and health systems. Over the past century, educators have devoted considerable thought and effort to how medical education might be improved. Analysing the language used to describe these initiatives provides insight into assumptions and practices. The authors conducted a Foucauldian critical discourse analysis of prominent recurrent themes in the North American medical education literature. The assembled archive of texts included works of Abraham Flexner, articles from the journal Academic Medicine (including its predecessor journals) and major medical education reports. A series of recurring themes were identified, including the need to avoid over-specialization, the importance of generalism, and the need to broaden criteria for medical student selection. Analysis of these recurring themes allowed identification of a prominent and recurrent discourse of 'new.' This discourse places focus on the future, ignores the ongoing historical nature of issues, suggests a sense of urgency and enables the proposal of modest solutions. It emphasizes changes for individual future doctors, thereby limiting consideration of institutional and systemic factors. Using the image of a carousel, the regular return of themes can be seen as carousel ponies circling around repeatedly in medical education. Identification of this medical education carousel provides an opportunity for medical educators to understand the historical nature of calls for change, and to consider what kinds of reform might be required if they wish to avoid this repetition in the future.

Context: The dominance of biomedical science in medical education has been contested throughout the past century, with recurring calls for more social science and humanities content. The centrality of biomedicine is frequently traced back to Abraham Flexner's 1910 report, 'Medical Education in the United States and Canada'. However, Flexner advocated for a scientist-doctor, rather than a curriculum filled with science content. Examination of the discourses of science since Flexner allows us to explore the place of various knowledge forms in medical education., Methods: A Foucauldian critical discourse analysis was performed, examining the discourses of scientific medicine in Flexner's works and North American medical education articles in subsequent decades. Foucault's methodological principles were used to identify statements, keywords and metaphors that emerged in the development of the discourses of scientific medicine, with particular attention to recurring arguments and shifts in the meaning and use of terms., Results: Flexner's scientist-doctor was an incisive thinker who drew upon multiple forms of knowledge. In the post-Flexner medical education reforms, the perception of science as a discursive object embedded in the curriculum became predominant over that of the scientist as the discursive subject who uses science. Science was then considered core curricular content and was discursively framed as impossibly vast. A parallel discourse, one of the insufficiency of biomedical science for the proper training of doctors, has existed over the past century, even as the humanities and social sciences have remained on the margins in medical school curricula., Conclusions: That discourses of scientific medicine have reinforced the centrality of biomedicine in medical education helps to explain the persistent marginalisation of other important knowledge domains. Medical educators need to be aware of the effects of these discourses on understandings of medical knowledge, particularly when contemplating curricular reform., (© Blackwell Publishing Ltd 2013.)

Objectives: There are significant health disparities according to sexual orientation and gender identity, particularly in mental health; however, very few mental health professionals specialise in caring for lesbian, gay, bisexual and transgender (LGBT) communities. The purpose of this study was to explore how providers with LGBT-focused practices have developed their capacity for working with these populations., Methods: Eight semi-structured interviews were conducted with practising mental health service providers with extensive experience serving LGBT individuals. Participants represented four professional disciplines: psychiatry (n = 2); social work (n = 3); psychotherapy (n = 2), and psychology (n = 1). The data were analysed for themes that were identified using a descriptive phenomenological approach., Results: All providers self-identified as members of LGBT communities; however, most agreed that this membership was not necessary to provide supportive, appropriate care for LGBT individuals. Providers described their self-identity as members of LGBT communities, associated lived experiences and recognition of the need for mental health services that are sensitive to the unique needs of LGBT individuals as influential factors in their career decisions. The lack of training opportunities and resources specific to the provision of LGBT-sensitive mental health services was highlighted. Provider recommendations included the introduction of mandatory LGBT health content in education curricula that addresses basic LGBT-related terminology, appropriate interview questions to facilitate the disclosure of sexual orientation and gender identity, information regarding the health impact of heterosexism and homophobia, and specific health care needs of sexual and gender identity minority people., Conclusions: Data from this study suggest there are few opportunities for medical providers to access training and gain expertise in the provision of care to LGBT people. Additional research is needed to consider whether the lack of LGBT health content in medical and psychiatric training programme curricula indirectly contributes to the health disparities experienced by these populations., (© Blackwell Publishing Ltd 2012.)

Objectives: In this qualitative study we examine how teachers' egalitarian or discriminatory behaviours and values at odds with those of the individual learner or the institution are perceived and absorbed by students, and how this hidden curriculum shapes the doctors students become., Methods: During 2011, a total of 120 randomly selected medical students from each class at three Canadian medical schools were electronically asked for examples of teachers' words, attitudes or behaviours that discriminated against or promoted equality towards a group or groups of doctors or patients. We examined the content of participants' examples of unexpected messages and their reactions to these. Responses were aggregated, sorted and coded for conceptual themes. An independent qualitative researcher repeated the analytic process and then engaged in discussion with us to reach consensus on themes and meanings., Results: The 76 (63%) respondents noted that attitudes in keeping with universally held, institutional values of equality towards, for example, homosexuals or marginalised populations were expressed, but also described role-modelling at odds with this. Patient characteristics such as obesity, drug abuse, mental illness and poverty were presented as signs of individual weakness or moral failing. Some teachers assumed immigrant status based on a student's or patient's skin colour or last name. Respondents described how women in medicine were maligned as potential surgeons and were expected to put family before career. Teachers denigrated doctors from specialties other than their own. Students reacted to discordant role-modelling by challenging, dissociating themselves, with silence or with confusion followed by attempts at individual transformation to realign careers and behaviours with those of teachers., Conclusions: When teaching contradicts institutional or learners' values, or is particularly inspiring, students notice and may be influenced to the extent that they rethink personal beliefs and plans to fit their future doctor selves to these models., (© Blackwell Publishing Ltd 2012.)

Objectives: The aim of the study was to assess the methodology and content of nutrition education during gastroenterology fellowship training and the variability among the different programs., Methods: A survey questionnaire was completed by 43 fellowship training directors of 62 active programs affiliated to the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, including sites in the United States, Canada, and Mexico. The data were examined for patterns in teaching methodology and coverage of specific nutrition topics based on level 1 training in nutrition, which is the minimum requirement according to the published North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition fellowship training guidelines., Results: The majority of the teaching was conducted by MD-degree faculty (61%), and most of the education was provided through clinical care experiences. Only 31% of the level 1 nutrition topics were consistently covered by >80% of programs, and coverage did not correlate with the size of the programs. Competency in nutrition training was primarily assessed through questions to individuals or groups of fellows (77% and 65%, respectively). Program directors cited a lack of faculty interested in nutrition and a high workload as common obstacles for teaching., Conclusions: The methodology of nutrition education during gastroenterology fellowship training is, for the most part, unstructured and inconsistent among the different programs. The minimum level 1 requirements are not consistently covered. The development of core curriculums and learning modules may be beneficial in improving nutrition education.

Context: Schema-based instruction may alter knowledge organisation and diagnostic reasoning strategies through the provision of structured knowledge to novice trainees. The effects of schema-based instruction on diagnostic accuracy and knowledge organisation have not been rigorously tested., Methods: Year 2 medical students were randomised to learn four cardiac diagnoses using schema-based instruction (n = 26) or traditional instruction (n = 27) on a high-fidelity cardiopulmonary simulator (CPS). Students completed case-based learning in groups of two to five and underwent individual written and practical tests. The written test consisted of questions testing features that linked or distinguished diagnoses (structured knowledge) and questions testing features of individual diagnoses (factual knowledge). A practical test of diagnostic accuracy on the CPS was performed for two diagnoses present in the learning phase (taught lesions) and two untaught lesions. A majority of students (n = 37, 70%) voluntarily returned for follow-up written testing 2-4 weeks later., Results: Learning time and accuracy did not differ between students on schema-based and those on traditional instruction. Students receiving schema-based instruction performed better on structured knowledge questions (p < 0.001) and no differently on factual knowledge questions (p = 0.7). Relative differences between groups remained unchanged on follow-up testing. Diagnostic success was higher in the schema-based instruction group for taught lesions (mean difference = 38%, 95% confidence interval [CI] 20-56; p < 0.001) and untaught lesions (mean difference = 31%, 95% CI 15-48; p < 0.001)., Conclusions: Schema-based instruction was associated with improved retention of structured knowledge and diagnostic performance among novices. This study provides important proof-of-concept for a schema-based approach and suggests there is substantial benefit to using this approach with novice trainees., (© Blackwell Publishing Ltd 2012.)

Context: Health care is one of many under-resourced areas in Aboriginal communities in Canada. Aboriginal people have substandard health compared with the general population, yet have less access to health care services. Not only is there a paucity of Aboriginal doctors, but it also appears that few non-Aboriginal doctors are willing or able to work in Aboriginal contexts., Objectives: This study examines the attitudes of family medicine residents towards providing health care to Aboriginal patients. The goal of this study was to assess the willingness of family medicine residents to work in Aboriginal health care and to elucidate the major factors that inform these attitudes., Methods: We conducted a cross-sectional survey of an urban cohort of family medicine residents using a convenience sample. Our survey instrument consisted of a questionnaire comprising a mixture of open-ended and closed questions., Results: Although a majority (52%, n = 27) of the family medicine residents were willing to work in Aboriginal contexts, many felt underprepared to do so (40%, n = 21). Residents who have had some exposure to Aboriginal issues and have had community experiences are more likely to state an intention to work in Aboriginal settings., Conclusions: The results of this study encourage the creation of educational experiences for medical residents that may promote a desire to work in Aboriginal communities., (© Blackwell Publishing Ltd 2011.)

More than ever are we facing the challenge of providing evidence that what we do responds to priority health needs and challenges of the ones we intend to serve: patients, citizens, families, communities and the nation at large. Which are those health needs and challenges? Who defines them? How do medical schools organize themselves to address them through their education, research and service delivery functions? Principles of social accountability call for an explicit three-tier engagement: identification of current and prospective social needs and challenges, adaptation of school's programmes to meet them and verification that anticipated effects have benefited society. Measurement tools need to be designed and tested to steer development in this direction, particularly to establish a meaningful relationship between inputs, processes, outputs and impact on health. The Global Consensus on Social Accountability of Medical Schools provides a unique opportunity to foster collaborative research and development in an area of great significance for the future of medical education.

Purpose: To review the recommendations of 15 U.S. and Canadian reports, published in the last decade, that call for significant change in medical education., Method: The author selected for review 15 reports published over the last ten years that emphasize general recommendations for change in medical education in the United States and Canada and that represent a broad spectrum of sources., Results: The purpose, methods, and content of each report are briefly described. The reports were selected because they address comprehensive change in medical education and have been recently published. The reports are categorized based on their inclusion of eight major themes: integrating the educational continuum, need for evaluation and research, new methods of financing, importance of leadership, emphasis on social accountability, use of new technology in education and medical practice, alignment with changes in the health care delivery system, and future directions in the health care workforce. The author provides an overview and synthesis of these reports and reveals a number of common themes to help medical educators implement changes in medical education in the next decade and beyond., Conclusions: There is remarkable congruence in the recommendations of the 15 reports. The author proposes that the problems facing contemporary medical education have been thoroughly identified and that it is time to set forth on meaningful new paths; many hopeful possibilities exist.

One of Abraham Flexner's legacies was the concept of a professional faculty community responsible for teaching, scholarly work, and the creation and nurturing of the academic environment in medical schools. Dramatic shifts in society, health care, and educational practice have occurred over the century since Flexner's report, and these shifts have resulted in changes and challenges for medical school faculty. Fundamental principles that were articulated in Flexner's work remain relevant today: medicine is a profession, and as such is responsible for the education of the next generation of physicians; and the essential work of the medical school is the education of current and future generations of physicians. Medical schools must reconsider and restate the required characteristics and work of faculty members. Furthermore, we must develop a core faculty with primary responsibility for the educational program, the teaching of students, and the creation and nurturing of the academic environment. Enhancing the diversity of the faculty community, providing necessary faculty development, and further clarifying the forms of scholarly work in medicine are three ways that individual schools and national organizations can advance the educational mission through support of the faculty.

Many forces, including the influential report of Abraham Flexner, acted to reform medical education in the early 20th century. Most physicians were not prepared to adopt recent advances in health care due to their poor medical training. This deficit was recognized in the 20 years before Flexner's report by several organizations, including the Illinois State Board of Health, the American Medical Association, and the Association of American Medical Colleges. Before 1910, each organization had engaged in at least one review of medical schools using defined standards and had identified many of the existing deficits. The number of medical schools already had begun to decrease, dropping from 160 in 1905 to 133 in 1910. Flexner drew heavily, but not exclusively, on the standards for medical education previously developed by other organizations. He visited 155 medical schools in the United States and Canada between December 1908 and April 1910. His 1910 report included a conceptual model of how modern medical education should be conducted and descriptions of each medical school that were explicit in both praise and censure.In the decade following the Flexner Report the number of medical schools decreased from 133 to 85. The actions of state medical licensing boards to deny recognition to poor schools sealed their fate. The remaining schools had higher entrance requirements, longer terms, and better resources. The author describes key factors that contributed to the success of the changes recommended by Flexner and others, and then posits why Flexner is still remembered.

One hundred years after Abraham Flexner released his report Medical Education in the United States and Canada, the spirit of reform is alive again. Reports in the United States and Canada have called for significant changes to medical education that will allow doctors to adapt to complex environments, work in teams, and meet a wide range of social needs. These reports call for clear educational outcomes but also for a flexible, individualized approach to learning. Whether or not change will result has much to do with the alignment between what is proposed and the nature of current societal discourses about how medical education should be conducted. Currently, two powerful and competing models of competence development are operating at odds with one another. The traditional one is time-based (a "tea-steeping" model, in which the student "steeps" in an educational program for a historically determined fixed time period to become a successful practitioner). This model directs attention to processes such as admission and curriculum design. The newer one is outcomes-based (an "i-Doc" model, a name suggested by the Apple i-Pod that infers that medical schools and residencies, like factories, can produce highly desirable products adapted to user needs and desires). This model focuses more on the functional capabilities of the end product (the graduate student, resident, or practicing physician). The author explores the implications of both time-based and outcomes-based models for medical education reform and proposes an integration of their best features.

The authors present an overview of the educational programs, infrastructure to support them, and the assessment strategies of 128 medical schools in the United States and Canada, based on reports submitted by those schools and published in this supplement to Academic Medicine. The authors explore many important changes that have occurred since the publication of the Flexner Report in 1910 as well as the progress that is evident since a similar collection of medical school reports was published in September 2000, also as a supplement to Academic Medicine. Drawing on the reports, the authors summarize, among other topics, the advances that have taken place in the support for faculty, the funding of medical student education, changes in pedagogy and assessment, and the expansion of medical education to distributed models and regional campuses.The authors observe that the reports from the 128 schools illustrate that medical student education has undergone and continues to undergo substantive change, has advanced markedly since the reforms stimulated by the Flexner Report, and has continued to evolve during the past decade. The reports illustrate the strength of support for the educational programs, even in a time of financial constraints, and the increasing recognition of the scholarly contributions of faculty through teaching. The authors provide examples of the changes in pedagogy and new topics in the required curriculum in the past decade and describe selected highlights of the 128 educational programs.

One hundred years ago, the time was right and the need was critical for medical education reform. Medical education had become a commercial enterprise with proprietary schools of variable quality, lectures delivered in crowded classrooms, and often no laboratory instruction or patient contact. Progress in science, technology, and the quality of medical care, along with political will and philanthropic support, contributed to the circumstances under which Abraham Flexner produced his report. Flexner was dismayed by the quality of many of the medical schools he visited in preparing the report. Many of the recommendations in Medical Education in the United States and Canada are still relevant, especially those concerning the physician as a practitioner whose purpose is more societal and preventive than individual and curative. Flexner helped establish standards for prerequisite education, framed medical school admission criteria, aided in the design of a curriculum introduced by the basic and followed by the clinical sciences, stipulated the resources necessary for medical education, and emphasized medical school affiliation with both a university and a strong clinical system. He proposed integration of basic and clinical sciences leading to contextual learning, active rather than passive learning, and the importance of philanthropy. Flexner's report poses several questions for the historian: How were his views on African American medical education shaped by his post-Civil War upbringing in Louisville? Was the report original or derivative? Why did it have such a large impact? This article describes Flexner's early life and the report's methodology and considers several of the historical questions.

The Association of Faculties of Medicine of Canada launched the Future of Medical Education in Canada (FMEC) Project in 2007. The FMEC Project's overarching goal was to comprehensively examine the current state of undergraduate medical education, concentrating on its alignment with current and future societal needs. Like Flexner's work, the FMEC Project used a process of reflection and renewal; unlike Flexner's work, the FMEC Project used multiple techniques to gather information, including literature reviews, key informant interviews, international visits, and a series of consultations with stakeholders and expert groups. The project's final report, The Future of Medical Education in Canada: A Collective Vision, put forth 10 recommendations that summarized priority areas for academic medicine and medical training in Canada at the start of the 21st century. The current article reviews FMEC Project recommendations in relation to the priorities set out by Flexner in 1910. In some areas, such as the scientific basis of medical education, there is striking congruence between Flexner's views and today's collective vision. In other areas, such as community-based learning, opinion appears to have shifted markedly over the past century, and concepts such as interprofessionalism may represent distinctly modern domains. While Flexnerian themes tend to center on the notion of medicine as science, present-day priorities converge on the link between academic medicine and societal needs. By looking back on Flexner's work, we can see where his vision has taken us. As well, we see more clearly the new frontiers that academic medicine will continue to explore.

Context: When individuals adapt their practice in order to solve novel or unexpected problems of practice, they are creating new knowledge. This form of innovation development is understood as a core competency of adaptive expertise and the basis for knowledge building community practice. However, little is known about the ways in which this knowledge, produced through daily, innovative problem solving, is developed, identified and shared by health care professionals., Methods: Following this line of inquiry, we conducted semi-structured interviews with a saturation sample of 15 clinical faculty staff at the University of Toronto., Results: A grounded theory analysis of the results showed that our participants held the view that innovation was focused on outcomes, developed through research practice and diffused for adoption in the broader community. As a result, their own individual improvements to daily practice were excluded from this view of innovation. Furthermore, their perceptions of innovation limited participants' engagement in the sort of collaborative process that is central to the practice of knowledge-building communities., Conclusions: This research demonstrated that thinking about innovation and innovative practice must be changed in order to foster the development of knowledge-building communities in medicine.

We have compared the conception and organization of medical education systems in France and Canada, taking into consideration key means and processes including the organization of curriculum, the selection of students, certification and licensure. The major objective of this comparison is to illustrate the degree to which the organization of medical education is influenced by the specific history and culture of each country. This is particularly important in an era of increasing internationalization in medical education. In Canada, a federalist orientation means a great deal of freedom for each province to determine its own criteria for medical licensure, and for each faculty of medicine to determine its own selection criteria and curriculum organization. Meanwhile, the evaluation of graduates of medical schools and later of specialties is organized at a national level. France, on the other hand, is much more centrist, and controls the "input" of students to medical schools and the nature of their curriculum. However, France allows each faculty of medicine to deliver a diploma that authorizes physician graduates to practice, without an evaluation of student performance at a national level. We show how the selection and evaluation of students in France are influenced by the French Revolutionary principles of "liberté" and the education of a national "elite", while in Canada the goals of "equity" and the guarantee of a level of "minimum competence" under pin a very different system. In conclusion, we highlight the important of taking into consideration these factors before undertaking reform of educational systems or transferring methods from one country to another.

Background: Outcomes-based education in the health professions has emerged as a priority for curriculum planners striving to align with societal needs. However, many struggle with effective methods of implementing such an approach. In this narrative, we describe the lessons learned from the implementation of a national, needs-based, outcome-oriented, competency framework called the CanMEDS initiative of The Royal College of Physicians and Surgeons of Canada., Methods: We developed a framework of physician competencies organized around seven physician "Roles": Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar, and Professional. A systematic implementation plan involved: the development of standards for curriculum and assessment, faculty development, educational research and resources, and outreach., Lessons Learned: Implementing this competency framework has resulted in successes, challenges, resistance to change, and a list of essential ingredients for outcomes-based medical education., Conclusions: A multifaceted implementation strategy has enabled this large-scale curriculum change for outcomes-based education.

Context: There is growing interest worldwide in the teaching of rural and community medicine to medical students. Medical teachers have a responsibility to introduce their students to different health experiences, in both urban and rural environments. The definition of a rural area can be problematic., Issue: There is no one universal definition of a rural area. This makes comparisons of data from differently defined areas problematic. Definitions of a rural area have been based on population size, access to health care, occupation and other socioeconomic variables, and political proclamations., Lessons Learned: There is no easy answer to such a complex issue as the definition of rurality. At best, medical teachers should inform their students that the definition of a rural area can be context specific, and may not be comparable between states. Defining the features of a particular rural area in academic writing may reduce some of the difficulties a reader may have in understanding the context. A universal definition of a rural area is not possible.

Objective: Malnutrition is highly prevalent in hospitalized patients and is often not identified by the medical staff. Clinical nutrition and nutritional assessment are often neglected components of the curriculum of medical schools. The effect of instruction of nutritional assessment early in medical school on nutritional practice in clinical training is unknown. Four years after the introduction of nutritional assessment in the medical school curriculum, we assessed the knowledge of medical students and residents of nutritional assessment and the practice of this clinical skill in hospitalized medical patients., Methods: We determined the nutritional status of 69 patients on a general medical ward within 10 d of their hospital admission. Hospital records were reviewed to determine the documentation of nutrition-related issues and practices. A questionnaire was then administered to the housestaff to determine their knowledge of assessment of nutritional status., Results: Significant malnutrition was found in 69% of patients. Only one patient was identified as being malnourished by the housestaff. References to nutritional status were recorded in two patient charts. History of weight loss, appetite status, current oral intake, and functional status were recorded for fewer than 33% of patients. Although measurements of visceral protein stores (albumin and prealbumin) did not correlate with nutritional status, medical students and residents considered these to be the best markers of nutritional status., Conclusions: Malnutrition is common in hospitalized patients. Instruction of second-year medical students in assessment of nutritional status does not result in improved knowledge or practice of nutritional assessment in the clinical training years as medical housestaff. Additional instruction in nutritional assessment during clinical training needs to be emphasized. Hospitals need to develop standardized protocols for assessment of nutritional status.

Objective: Conditions relating to the ear, nose and throat are very frequent problems encountered by general pediatricians. Similarly, a major percentage of patients seen and operated on by the general otolaryngologist are of the pediatric age group. The pilot study demonstrated that pediatric program directors of both specialties in Canada have identified a deficiency of cross-training and desire the need for more cross-training. The aim of this study was to survey practicing physicians of both specialties for their input., Methods: Surveys were sent to a large cross-section of pediatricians and otolaryngologists in Canada. They were asked to complete a questionnaire relating to their training experience, their desired training, important topics and general comments. Demographic data were collected including generalist versus sub-specialist, the year that residency was completed and country of training. Results were tabulated and analyzed., Results: The response rate was high, being 70.6% and 76.2% for pediatricians and otolaryngologists, respectively. One hundred percent of pediatricians indicated that formal training by otolaryngologists was necessary, while 95% of otolaryngologists indicate a need for formal training by pediatricians during residency. Pediatricians desire more training using all three educational venues, namely lectures, clinics and rotations. While they are receiving lectures more often, they indicate that clinics are the most important mode of education. Otolaryngologists desire more formal training by pediatricians in the areas of lectures and clinics. They indicate the most important mode of education is lectures. There was no significant difference between generalists and sub-specialists or based on country of training for either group. There is some indication, in both specialties, of an increase of cross-training occurring within the past five years., Conclusions: This study has shown that there is a perceived deficiency of cross-training between the two specialties. Both pediatricians and otolaryngologists have indicated that they need more formal cross-training. This is a very important area to address, as this study relates directly to the optimum health of children in Canada and worldwide.