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It is postulated that implementation of Competency by Design (CBD) in Royal College of Physicians and Surgeons of Canada (RCPSC) programs has helped enhanced skills programs in emergency medicine (CCFP(EM)) move towards a more competency-based residency. The objectives of the study were to identify major competency-based medical educational (CBME) components of CCFP(EM) programs across the country; and determine how programs are delivering these components.After a rigorous development process (expert content development, and pilot testing), a survey questionnaire was administered to all 17 CCFP(EM) program directors using a modified Dillman technique. Questions were structured and framed using the core components framework of CBME. The final survey included a total of 44 questions under six sections.There was a 100% response rate. Only 65% of programs currently map their program's curriculum to an explicit outcomes-based framework. All but one program plan to map their program's curriculum to Core Professional Activities that were released by the College of Family Physicians of Canada (CFPC) in May 2021. In 35% of programs, a curriculum is organized around developmental competencies that support resident progression. Individual coaches or a coaching team follow residents longitudinally in 65% of programs. In 81% of programs, the program meets with a resident at regular, pre-defined intervals to discuss their progression. In terms of assessment: data from direct observations are incorporated 94% of the time; 29% of programs have specific criteria for advancement; and all programs have a Competence Committee. With the introduction of CBD in RCPSC programs, 71% of program directors felt there was less understanding of the unique needs of CCFP(EM) residents.This study summarizes the current state of CBME in CCFP(EM) programs. While many components of CBME are incorporated, further development and innovation is needed to fully adapt CBME to a 1-year training program.RéSUMé: INTRODUCTION: Il est postulé que la mise en œuvre de la méthode " Compétence par conception " (CPC) dans les programmes du Collège royal des médecins et chirurgiens du Canada (CRMCC) a aidé les programmes de compétences améliorées en médecine d'urgence (CCMF(MU)) à évoluer vers une résidence davantage axée sur les compétences. Les objectifs de l'étude étaient d'identifier les principales composantes de la formation médicale fondée sur les compétences (FMFC) des programmes CCMF(EM) à travers le pays et de déterminer comment les programmes offrent ces composantes. MéTHODES: Après un processus de développement rigoureux (élaboration du contenu par des experts et essai pilote), un questionnaire d'enquête a été administré aux 17 directeurs de programme du CCMF(MU) en utilisant une technique Dillman modifiée. Les questions ont été structurées et encadrées en utilisant le cadre des composantes essentielles de la CBME. L'enquête finale comprenait un total de 44 questions réparties en six sections. RéSULTATS: Le taux de réponse a été de 100 %. Seulement 65 % des programmes font actuellement correspondre le curriculum de leur programme à un cadre explicite basé sur les résultats. Tous les programmes sauf un prévoient d'adapter le curriculum de leur programme aux activités professionnelles de base qui ont été publiées par le Collège des médecins de famille du Canada (CMFC) en mai 2021. Dans 35 % des programmes, un programme d'études est organisé autour des compétences de développement qui soutiennent la progression des résidents. Des coachs individuels ou une équipe de coachs suivent les résidents de manière longitudinale dans 65 % des programmes. Dans 81 % des programmes, le programme rencontre un résident à intervalles réguliers et prédéfinis pour discuter de sa progression. Pour ce qui est de l’évaluation : les données issues des observations directes sont intégrées dans 94 % des cas ; 29 % des programmes ont des critères spécifiques pour l'avancement ; et tous les programmes ont un comité de compétence. Avec l'introduction du CBD dans les programmes du CRMCC, 71 % des directeurs de programme ont estimé que les besoins uniques des résidents du CCMF(MU) étaient moins bien compris. CONCLUSION: Cette étude résume l’état actuel du FMFC dans les programmes du CCMF(MU). Bien que de nombreux éléments de FMFC soient incorporés, un développement et une innovation supplémentaires sont nécessaires pour adapter pleinement FMFC à un programme de formation d'un an. MOTS CLéS: Médecine familiale/médecine d'urgence, compétences avancées, programme de médecine d'urgence, CCMF(MU), formation médicale fondée sur les compétences, FMFC, compétence par conception, CFC.

This study aimed to provide comprehensive diagnostic and candidate analyses in a pediatric rare disease cohort through the Genomic Answers for Kids program.Extensive analyses of 960 families with suspected genetic disorders included short-read exome sequencing and short-read genome sequencing (srGS); PacBio HiFi long-read genome sequencing (HiFi-GS); variant calling for single nucleotide variants (SNV), structural variant (SV), and repeat variants; and machine-learning variant prioritization. Structured phenotypes, prioritized variants, and pedigrees were stored in PhenoTips database, with data sharing through controlled access the database of Genotypes and Phenotypes.Diagnostic rates ranged from 11% in patients with prior negative genetic testing to 34.5% in naive patients. Incorporating SVs from genome sequencing added up to 13% of new diagnoses in previously unsolved cases. HiFi-GS yielded increased discovery rate with4-fold more rare coding SVs compared with srGS. Variants and genes of unknown significance remain the most common finding (58% of nondiagnostic cases).Computational prioritization is efficient for diagnostic SNVs. Thorough identification of non-SNVs remains challenging and is partly mitigated using HiFi-GS sequencing. Importantly, community research is supported by sharing real-time data to accelerate gene validation and by providing HiFi variant (SNV/SV) resources from1000 human alleles to facilitate implementation of new sequencing platforms for rare disease diagnoses.

Due to the COVID pandemic, restrictions were put in place mandating that all residency interviews be transitioned to a virtual format. Canadian CCFP(EM) programs were among the first to embark on this universal virtual interview process for resident selection. Although there have been several recent publications suggesting best practice guidelines for virtual interviews in trainee selection, pragmatic experiences and opinions from Program Directors (PDs) are lacking. This study aimed to elicit the experiences and perspectives of CCFP(EM) PDs after being amongst the first to conduct universal virtual interviews in Canada.A 17-item online survey was created and distributed to all CCFP(EM) PDs (n = 17). It explored the virtual interview format employed, perceived advantages and disadvantages of a virtual configuration, confidence in determining a candidate's rank order, and PD preference for employing a virtual interview format in the future. It also elicited practical advice to conduct a smooth and successful virtual interview day.The survey response rate was 76.5% (13/17). Nine respondents (69.2%) agreed that the virtual interview format enabled them to confidently determine a candidate's rank order. With respect to preference for future use of virtual interviews, 23.1% agreed, 38.5% disagreed and 38.5% neither agreed nor disagreed. Inductive thematic analysis of free text responses revealed themes related to virtual interview advantages (time, financial, and resource costs), disadvantages (difficulty promoting smaller programs, getting a 'feel' for candidates and assessing their interpersonal skills), and practical tips to facilitate virtual interview processes.Once restrictions are lifted, cost-saving advantages must be weighed against suggested disadvantages such as showcasing program strengths and assessing interpersonal skills in choosing between traditional and virtual formats. Should virtual interviews become a routine part of resident selection, the advice suggested in this study may be considered to help optimize a successful virtual interview process.RéSUMé: OBJECTIF: En raison de la pandémie de COVID-19, des restrictions ont été mises en place pour obliger toutes les entrevues de résidence à passer à un format virtuel. Les programmes canadiens CCMF(MU) ont été parmi les premiers à se lancer dans ce processus universel d'entrevue virtuelle pour la sélection des résidents. Bien qu’il y ait eu plusieurs publications récentes suggérant des lignes directrices de pratiques exemplaires pour les entrevues virtuelles dans la sélection des stagiaires, les expériences et les opinions pragmatiques des directeurs de programme (DP) font défaut. Cette étude visait à recueillir les expériences et les points de vue des DP du CCMF(MU) après avoir été parmi les premiers à mener des entrevues virtuelles universelles au Canada. MéTHODES: Une enquête en ligne de 17 questions a été créée et distribuée à tous les DP du CCMF(MU) (n=17). Elle a exploré le format d'entretien virtuel employé, les avantages et inconvénients perçus d'une configuration virtuelle, la confiance dans la détermination de l'ordre de classement d'un candidat, et la préférence des DP pour l'emploi d'un format d'entretien virtuel à l'avenir. Elle a également permis de recueillir des conseils pratiques pour mener à bien une journée d'entretiens virtuels. RéSULTATS: Le taux de réponse à l'enquête a été de 76,5 % (13/17). Neuf répondants (69,2 %) ont convenu que le format d'entretien virtuel leur a permis de déterminer avec confiance l'ordre de classement d'un candidat. En ce qui concerne la préférence pour l’utilisation future des entrevues virtuelles, 23,1 % étaient d’accord, 38,5 % étaient en désaccord et 38,5 % n’étaient ni d’accord ni en désaccord. L'analyse thématique inductive des réponses en texte libre a révélé des thèmes liés aux avantages des entretiens virtuels (coûts en temps, en argent et en ressources), aux inconvénients (difficulté à promouvoir les petits programmes, à se faire une idée des candidats et à évaluer leurs compétences interpersonnelles) et aux conseils pratiques pour faciliter les processus d'entretien virtuel. CONCLUSION: Une fois les restrictions levées, les avantages liés à la réduction des coûts doivent être mis en balance avec les inconvénients suggérés, tels que la mise en valeur des points forts du programme et l'évaluation des compétences interpersonnelles, lors du choix entre les formats traditionnels et virtuels. Si les entretiens virtuels devaient devenir un élément de routine dans la sélection des résidents, les conseils suggérés dans cette étude pourraient être pris en compte pour aider à optimiser un processus d'entretien virtuel réussi.

Previous studies focusing on the age disparity in COVID-19 severity have suggested that younger individuals mount a more robust innate immune response in the nasal mucosa after infection with SARS-CoV-2. However, it is unclear if this reflects increased immune activation or increased immune residence in the nasal mucosa. We hypothesized that immune residency in the nasal mucosa of healthy individuals may differ across the age range. We applied single-cell RNA-sequencing and measured the cellular composition and transcriptional profile of the nasal mucosa in 35 SARS-CoV-2 negative children and adults, ranging in age from 4 months to 65 years. We analyzed in total of ~ 30,000 immune and epithelial cells and found that age and immune cell proportion in the nasal mucosa are inversely correlated, with little evidence for structural changes in the transcriptional state of a given cell type across the age range. Orthogonal validation by epigenome sequencing indicate that it is especially cells of the innate immune system that underlie the age-association. Additionally, we characterize the predominate immune cell type in the nasal mucosa: a resident T cell like population with potent antiviral properties. These results demonstrate fundamental changes in the immune cell makeup of the uninfected nasal mucosa over the lifespan. The resource we generate here is an asset for future studies focusing on respiratory infection and immunization strategies.

We implemented a novel transition-to-practice curriculum incorporating four new processes to prepare CCFP(EM) residents for independent practice. These elements were: 1) explicit sequencing of competency progression; 2) establishment of coaching teams; 3) establishment of independent shifts; and 4) implementation of a transition-to-practice seminar series. Exit surveys of residents rated the new curriculum highly with 15/17 (88.2%) residents reporting they felt prepared for independent practice. All residents rated competency progression, coaching teams, independent shifts and transition-to-practice series favourably. This framework can be used by other 1-year enhanced skills or other fellowship programs to prepare their residents for independent practice.

Growing literature within postgraduate medical education demonstrates that female resident physicians experience gender bias throughout their training and future careers. This scoping review aims to describe the current body of literature on gender differences in emergency medicine (EM) resident assessment.We conducted a scoping review which adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. We included research involving resident physicians or fellows in EM (population and context), which focused on the impact of gender on assessments (concept). We searched seven databases from the databases' inception to April 4, 2022. Two reviewers independently screened citations, completed full-text review, and abstracted data. A third reviewer resolved any discrepancies.A total of 667 unique citations were identified; 10 studies were included, and all were conducted within the United States. Four studies reported differences in EM resident assessments attributable to gender within workplace-based assessments (qualitative comments and quantitative scores) by both attending physicians and nonphysicians. Six studies investigating clinical competency committee scores, procedural scores, and simulation-based assessments did not report any significant differences attributable to gender.This scoping review found that gender bias exists within EM resident assessment most notably at the level of narrative comments typically received via workplace-based assessments. As female EM residents receive higher rates of negative or critical comments and discordant feedback documented on assessment, these findings raise concern about added barriers female EM residents may face while progressing through residency and the impact on their clinical and professional development.

A key component of competency-based medical education (CBME) is direct observation of trainees. Direct observation has been emphasized as integral to workplace-based assessment (WBA) yet previously identified challenges may limit its successful implementation. Given these challenges, it is imperative to fully understand the value of direct observation within a CBME program of assessment. Specifically, it is not known whether the quality of WBA documentation is influenced by observation type (direct or indirect).The objective of this study was to determine the influence of observation type (direct or indirect) on quality of entrustable professional activity (EPA) assessment documentation within a CBME program. EPA assessments were scored by four raters using the Quality of Assessment for Learning (QuAL) instrument, a previously published three-item quantitative measure of the quality of written comments associated with a single clinical performance score. An analysis of variance was performed to compare mean QuAL scores among the direct and indirect observation groups. The reliability of the QuAL instrument for EPA assessments was calculated using a generalizability analysis.A total of 244 EPA assessments (122 direct observation, 122 indirect observation) were rated for quality using the QuAL instrument. No difference in mean QuAL score was identified between the direct and indirect observation groups (p = 0.17). The reliability of the QuAL instrument for EPA assessments was 0.84.Observation type (direct or indirect) did not influence the quality of EPA assessment documentation. This finding raises the question of how direct and indirect observation truly differ and the implications for meta-raters such as competence committees responsible for making judgments related to trainee promotion.

Background In 2018, Canadian postgraduate emergency medicine (EM) programs began implementing a competency-based medical education (CBME) assessment program. Studies evaluating these programs have focused on broad outcomes using data from national bodies and lack data to support program-specific improvement. Objective We evaluated the implementation of a CBME assessment program within and across programs to identify successes and opportunities for improvement at the local and national levels. Methods Program-level data from the 2018 resident cohort were amalgamated and analyzed. The number of entrustable professional activity (EPA) assessments (overall and for each EPA) and the timing of resident promotion through program stages were compared between programs and to the guidelines provided by the national EM specialty committee. Total EPA observations from each program were correlated with the number of EM and pediatric EM rotations. Results Data from 15 of 17 (88%) programs containing 9842 EPA observations from 68 of 77 (88%) EM residents in the 2018 cohort were analyzed. Average numbers of EPAs observed per resident in each program varied from 92.5 to 229.6, correlating with the number of blocks spent on EM and pediatric EM (r = 0.83, P < .001). Relative to the specialty committee's guidelines, residents were promoted later than expected (eg, one-third of residents had a 2-month delay to promotion from the first to second stage) and with fewer EPA observations than suggested. Conclusions There was demonstrable variation in EPA-based assessment numbers and promotion timelines between programs and with national guidelines.

ObjectivesThe Emergency Medicine (EM) Specialty Committee of the Royal College of Physicians and Surgeons of Canada (RCPSC) specifies that resuscitation entrustable professional activities (EPAs) can be assessed in the workplace and simulated environments. However, limited validity evidence for these assessments in either setting exists. We sought to determine if EPA ratings improve over time and whether an association exists between ratings in the workplace v. simulation environment.MethodsAll Foundations EPA1 (F1) assessments were collected for first-year residents (n = 9) in our program during the 2018–2019 academic year. This EPA focuses on initiating and assisting in the resuscitation of critically ill patients. EPA ratings obtained in the workplace and simulation environments were compared using Lin's concordance correlation coefficient (CCC). To determine whether ratings in the two environments differed as residents progressed through training, a within-subjects analysis of variance was conducted with training environment and month as independent variables.ResultsWe collected 104 workplace and 36 simulation assessments. No correlation was observed between mean EPA ratings in the two environments (CCC(8) = -0.01; p = 0.93). Ratings in both settings improved significantly over time (F(2,16) = 18.8; p < 0.001; η2= 0.70), from 2.9 ± 1.2 in months 1–4 to 3.5 ± 0.2 in months 9–12. Workplace ratings (3.4 ± 0.1) were consistently higher than simulation ratings (2.9 ± 0.2) (F(2,16) = 7.2; p = 0.028; η2= 0.47).ConclusionsNo correlation was observed between EPA F1 ratings in the workplace v. simulation environments. Further studies are needed to clarify the conflicting results of our study with others and build an evidence base for the validity of EPA assessments in simulated and workplace environments.

This interactive session was held at the 51st Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) in preparation for the transition of Pediatric Surgery training in Canada to Competency by Design (a CBME-based model of residency training developed by the Royal College of Physicians and Surgeons of Canada).

BackgroundCompetence committees play a key role in a competency-based system of assessment. These committees are tasked with reviewing and synthesizing clinical performance data to make judgments regarding residents’ competence. Canadian emergency medicine (EM) postgraduate training programs recently implemented competence committees; however, a paucity of literature guides their work.ObjectiveThe objective of this study was to develop consensus-based recommendations to optimize the function and decisions of competence committees in Canadian EM training programs.MethodsSemi-structured interviews of EM competence committee chairs were conducted and analyzed. The interview guide was informed by a literature review of competence committee structure, processes, and best practices. Inductive thematic analysis of interview transcripts was conducted to identify emerging themes. Preliminary recommendations, based on themes, were drafted and presented at the 2019 CAEP Academic Symposium on Education. Through a live presentation and survey poll, symposium attendees representing the national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback and identified consensus among symposium attendees on a final set of nine high-yield recommendations.ConclusionThe Canadian EM community used a structured process to develop nine best practice recommendations for competence committees addressing: committee membership, meeting processes, decision outcomes, use of high-quality performance data, and ongoing quality improvement. These recommendations can inform the structure and processes of competence committees in Canadian EM training programs.

The extravillous trophoblast (EVT) cell lineage is a key feature of placentation and successful pregnancy. Knowledge of transcriptional regulation driving EVT cell development is limited. Here, we mapped the transcriptome and epigenome landscape as well as chromatin interactions of human trophoblast stem (TS) cells and their transition into EVT cells. Integration of chromatin accessibility, long-range chromatin interactions, transcriptomic, and transcription factor (TF) binding motif enrichment enabled identification of TFs and regulatory mechanisms associated with EVT cell development. Functional roles forTFAP2C,SNAI1,andEPAS1in the regulation of EVT cell development were elucidated.EPAS1was identified as an upstream regulator of key EVT cell TFs, includingASCL2andSNAI1and together with its target genes, was linked to pregnancy loss and birth weight. Collectively, we have revealed activation of a dynamic regulatory network that provides a framework for understanding EVT cell specification in trophoblast cell lineage development and human placentation.

INTRODUCTION: Point‐of‐care ultrasound (POCUS) has become an important diagnostic tool in acute care medicine; however, little is known about the biomechanical differences between novice and expert practitioners. METHODS: A low‐cost ($50 CAD) gyroscope and accelerometer integrated sensor was assembled and affixed to an ultrasound probe. Seventeen participants, nine novices and eight experts, were recruited to perform three abdominal and four cardiac scans on a standardized patient. Participant demographics, time per scan, average acceleration, average angular velocity, decay in acceleration and angular velocity over time, and frequency of probe movements were analyzed. Video capture with blinded video review was scored. RESULTS: On video review, experts had higher image optimization and acquisition scores for both abdominal and cardiac scans. Experts had shorter scan times for abdominal (7 s vs. 26 s, p = 0.003) and cardiac (11 s vs. 26 s, p

Exposure to adverse early-life environments (AME) increases the incidence of developing adult-onset non-alcoholic fatty liver disease (NAFLD). DNA methylation has been postulated to link AME and late-onset diseases. This study aimed to investigate whether and to what extent the hepatic DNA methylome was perturbed prior to the development of NAFLD in offspring exposed to AME in mice. AME constituted maternal Western diet and late-gestational stress. Male offspring livers at birth (d0) and weaning (d21) were used for evaluating the DNA methylome and transcriptome using the reduced representation of bisulfite sequencing and RNA-seq, respectively. We found AME caused 5879 differentially methylated regions (DMRs) and zero differentially expressed genes (DEGs) at d0 and 2970 and 123, respectively, at d21. The majority of the DMRs were distal to gene transcription start sites and did not correlate with DEGs. The DEGs at d21 were significantly enriched in GO biological processes characteristic of liver metabolic functions. In conclusion, AME drove changes in the hepatic DNA methylome, which preceded perturbations in the hepatic metabolic transcriptome, which preceded the onset of NAFLD. We speculate that subtle impacts on dynamic enhancers lead to long-range regulatory changes that manifest over time as gene network alternations and increase the incidence of NAFLD later in life.

This study evaluated the fidelity of competence committee (CC) implementation in Canadian postgraduate specialist training programs during the transition to competency-based medical education (CBME).A national survey of CC chairs was distributed to all CBME training programs in November 2019. Survey questions were derived from guiding documents published by the Royal College of Physicians and Surgeons of Canada reflecting intended processes and design.Response rate was 39% (113/293) with representation from all eligible disciplines. Committee size ranged from 3 to 20 members, 42% of programs included external members, and 20% included a resident representative. Most programs (72%) reported that a primary review and synthesis of resident assessment data occurs prior to the meeting, with some data reviewed collectively during meetings. When determining entrustable professional activity (EPA) achievement, most programs followed the national specialty guidelines closely with some exceptions (53%). Documented concerns about professionalism, EPA narrative comments, and EPA entrustment scores were most highly weighted when determining resident progress decisions.Heterogeneity in CC implementation likely reflects local adaptations, but may also explain some of the variable challenges faced by programs during the transition to CBME. Our results offer educational leaders important fidelity data that can help inform the larger evaluation and transformation of CBME.

Organizational readiness is critical for successful implementation of an innovation. We evaluated program readiness to implement Competence by Design (CBD), a model of Competency-Based Medical Education (CBME), among Canadian postgraduate training programs. A survey of program directors was distributed 1 month prior to CBD implementation in 2019. Questions were informed by the R = MC2 framework of organizational readiness and addressed: program motivation, general capacity for change, and innovation-specific capacity. An overall readiness score was calculated. An ANOVA was conducted to compare overall readiness between disciplines. Survey response rate was 42% (n = 79). The mean overall readiness score was 74% (30���98%). There was no difference in scores between disciplines. The majority of respondents agreed that successful implementation of CBD was a priority (74%), and that their leadership (94%) and faculty and residents (87%) were supportive of change. Fewer perceived that CBD was a move in the right direction (58%) and that implementation was a manageable change (53%). Curriculum mapping, competence committees and programmatic assessment activities were completed by >90% of programs, while

Background delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol. Objectives we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients. Methods we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified. Results a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture. Conclusion this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.

In June 2019, The Ottawa Hospital launched the Epic electronic health record system, which transitioned all departments from a primarily paper-based system to an electronic system using a 1-day "big bang" approach. We sought to evaluate emergency physicians' satisfaction with system implementation and perception of its impact on clinical practice in an academic emergency department (ED) setting.Four electronic surveys were distributed to staff during pre-implementation (1-month prior [May 2019]) and post-implementation (1-month [July 2019], 9-month [March 2020], and 20-month [February 2021]) time periods. 5-point Likert scales were used to rate agreement with statements. Responses were compared using the Cochran-Mantel-Haenszel trend test to assess for significant differences.Response rates were consistent, ranging between 41 and 51%, with the exception of +9 months which was 27%. The majority of respondents were staff, working 8-15 shifts/month, with ≤ 10 years in practice. General satisfaction and confidence improved substantially from pre-implementation to 20 months post-implementation. Personalization sessions were perceived as not effective and lacking in quality, particularly immediately after Epic launch. Although clinical workflow tasks got easier, there were sustained challenges in efficiency and patient flow, including number of patients seen/hour, time spent after shift-end, and time spent on post-shift documentation.Although satisfaction and system confidence improved over time, there were sustained difficulties in overall efficiency long after implementation, with opportunities for future optimization. Training was lacking in terms of relevance to emergency physician workflow. These factors should be considered in future electronic health record implementations in ED settings.RéSUMé: OBJECTIFS: En juin 2019, l'Hôpital d'Ottawa a lancé le système de dossiers de santé électroniques Epic, ce qui a permis de faire passer tous les services d'un système principalement basé sur le papier à un système électronique en utilisant une approche " big bang " d'une journée. Nous avons cherché à évaluer la satisfaction des médecins urgentistes quant à la mise en œuvre du système et la perception de son impact sur la pratique clinique dans un service d'urgence universitaire. MéTHODES: Quatre sondages électroniques ont été distribués au personnel pendant les périodes précédant la mise en œuvre (1 mois avant [mai 2019]) et suivant la mise en œuvre (1 mois [juillet 2019], 9 mois [mars 2020] et 20 mois [février 2021]). Des échelles de Likert à 5 points ont été utilisées pour évaluer l’accord avec les énoncés. Les réponses ont été comparées à l'aide du test de tendance de Cochran-Mantel-Haenszel pour évaluer les différences significatives. RéSULTATS: Les taux de réponse étaient constants, allant de 41 % à 51 %, à l'exception de celui de +9 mois qui était de 27 %. La majorité des répondants étaient des employés, travaillant de 8 à 15 quarts par mois, avec moins de 10 ans de pratique. La satisfaction générale et la confiance se sont considérablement améliorées entre la période précédant la mise en œuvre et la période de 20 mois suivant la mise en œuvre. Les sessions de personnalisation ont été perçues comme inefficaces et manquant de qualité, en particulier immédiatement après le lancement d'Epic. Bien que les tâches du flux de travail clinique aient été facilitées, l'efficacité et le flux de patients ont continué à poser problème, notamment le nombre de patients vus par heure, le temps passé après la fin du quart de travail et le temps consacré à la documentation après le quart de travail. CONCLUSIONS: Bien que la satisfaction et la confiance dans le système se soient améliorées au fil du temps, il y a eu des difficultés persistantes dans l'efficacité globale longtemps après la mise en œuvre, avec des possibilités d'optimisation future. La formation manquait de pertinence par rapport au flux de travail des médecins urgentistes. Ces facteurs devraient être pris en compte dans les futures mises en œuvre de dossiers médicaux électroniques dans les services d'urgence.

PURPOSE Postgraduate training programs are incorporating feedback from registered nurses (RNs) to facilitate holistic assessments of resident performance. RNs are a potentially rich source of feedback because they often observe trainees during clinical encounters when physician supervisors are not present. However, RN perspectives about sharing feedback have not been deeply explored. This study investigated RN perspectives about providing feedback and explored the facilitators and barriers influencing their engagement. METHOD Constructivist grounded theory methodology was used in interviewing 11 emergency medicine and 8 internal medicine RNs at 2 campuses of a tertiary care academic medical center in Ontario, Canada, between July 2019 and March 2020. Interviews explored RN experiences working with and observing residents in clinical practice. Data collection and analysis were conducted iteratively. Themes were identified using constant comparative analysis. RESULTS RNs felt they could observe authentic day-to-day behaviors of residents often unwitnessed by supervising physicians and offer unique feedback related to patient advocacy, communication, leadership, collaboration, and professionalism. Despite a strong desire to contribute to resident education, RNs were apprehensive about sharing feedback and reported barriers related to hierarchy, power differentials, and a fear of overstepping professional boundaries. Although infrequent, a key stimulus that enabled RNs to feel safe in sharing feedback was an invitation from the supervising physician to provide input. CONCLUSIONS Perceived hierarchy in academic medicine is a critical barrier to engaging RNs in feedback for residents. Accessing RN feedback on authentic resident behaviors requires dismantling the negative effects of hierarchy and fostering a collaborative interprofessional working environment. A critical step toward this goal may require supervising physicians to model feedback-seeking behavior by inviting RNs to share feedback. Until a workplace culture is established that validates nurses' input and creates safe opportunities for them to contribute to resident education, the voices of nurses will remain unheard.

PURPOSETo provide comprehensive diagnostic and candidate analyses in a pediatric rare disease cohort through the Genomic Answers for Kids (GA4K) program.METHODSExtensive analyses of 960 families with suspected genetic disorders including short-read exome (ES) and genome sequencing (srGS); PacBio HiFi long-read GS (HiFi-GS); variant calling for small-nucleotide (SNV), structural (SV) and repeat variants; and machine-learning variant prioritization. Structured phenotypes, prioritized variants and pedigrees are stored in PhenoTips database, with data sharing through controlled access (dbGAP).RESULTSDiagnostic rates ranged from 11% for cases with prior negative genetic tests to 34.5% in naïve patients. Incorporating SVs from GS added up to 13% of new diagnoses in previously unsolved cases. HiFi-GS yielded increased discovery rate with >4-fold more rare coding SVs than srGS. Variants and genes of unknown significance (VUS/GUS) remain the most common finding (58% of non-diagnostic cases).CONCLUSIONComputational prioritization is efficient for diagnostic SNVs. Thorough identification of non-SNVs remains challenging and is partly mitigated by HiFi-GS sequencing. Importantly, community research is supported by sharing real-time data to accelerate gene validation, and by providing HiFi variant (SNV/SV) resources from >1,000 human alleles to facilitate implementation of new sequencing platforms for rare disease diagnoses.

Empathy and quality of educational environment appear to be inversely correlated with burnout but the relationship between the two is largely unknown. Our primary objective was to examine the relationship between postgraduate educational environment and empathy. Secondary objectives included impact of gender, residency year and on- versus off-service context on levels of empathy and educational environment.A modified Dillman approach was used to conduct an email survey of Canadian Royal College Emergency Medicine residents in June 2020. The survey instrument included: demographic data, Toronto Empathy Questionnaire (TEQ) and Scan of Postgraduate Educational Environment Domains (SPEED). Logistic and linear regressions evaluated the association between TEQ and SPEED, and mean SPEED scores and covariates, respectively.Response rate was 38% (138/363) with representation from all programs. Respondents were mean 30 years of age, 59% men and 25%, 20%, 18%, 24%, and 13% in postgraduate year (PGY) 1-5, respectively. There was no statistically significant association between high/low TEQ scores and mean SPEED score (p = 0.97). There were no statistically significant associations between any of the covariates and high/low TEQ scores (gender, p = 0.21; PGY, p = 0.58; on-versus off-service, p = 0.46) or mean SPEED score (gender, p = 0.95; PGY, p = 0.48; on- versus off-service, p = 0.07). Emergency medicine residents rated their educational environment on average 3.44 (+/- 0.43) out of four. 39 of 134 residents were found to have low empathy.There was no association between empathy and educational environment. Further research is needed to elucidate modifiable factors contributing to the development of low empathy in emergency medicine residents.RéSUMé: OBJECTIF: L'empathie et la qualite de l'environnement educatif semblent etre inversement correlees a l'epuisement professionnel, mais la relation entre les deux est largement inconnue. Notre objectif principal etait d'examiner la relation entre l'environnement educatif de troisieme cycle et l'empathie. Les objectifs secondaires comprenaient l'impact du sexe, de l'annee de residence et du contexte en service ou hors service sur les niveaux d'empathie et l'environnement educatif. MéTHODES: Une approche Dillman modiiee a ete utilisee pour mener une enquete par courriel aupres des residents du College royal canadien de medecine d'urgence en juin 2020. L'instrument d'enquete comprenait : des donnees demographiques, le Toronto Empathy Questionnaire (TEQ) et le Scan of Postgraduate Educational Environment Domains (SPEED). Des regressions logistiques et lineaires ont evalue l'association entre TEQ et SPEED, et les scores SPEED moyens et les covariables, respectivement. RéSULTATS: Le taux de reponse etait de 38 % (138/363) avec une representation de tous les programmes. Les repondants etaient ages en moyenne de 30 ans, 59 % d'hommes et 25%, 20%, 18%, 24% et 13% de la 1

ObjectivesCricothyrotomy is an intervention performed to salvage “can't intubate, can't ventilate” situations. Studies have shown poor accuracy with landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models.MethodsFive male and female volunteers were models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane; 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Overall accuracy and accuracy stratified by sex and obesity status were calculated.ResultsOverall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30–65%, p < 0.0001), and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12–51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI = −0.081–0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1–0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33).ConclusionWe found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and a longer time to secure the airway. Improved training techniques may reduce failed attempts and improve the time to secure the airway.

The complex relationship between metabolic disease risk and body fat distribution in humans involves cellular characteristics which are specific to body fat compartments. Here we show depot-specific differences in the stromal vascual fraction of visceral and subcutaneous adipose tissue by performing single-cell RNA sequencing of tissue specimen from obese individuals. We characterize multiple immune cells, endothelial cells, fibroblasts, adipose and hematopoietic stem cell progenitors. Subpopulations of adipose-resident immune cells are metabolically active and associated with metabolic disease status and those include a population of potential dysfunctional CD8+ T cells expressing metallothioneins. We identify multiple types of adipocyte progenitors that are common across depots, including a subtype enriched in individuals with type 2 diabetes. Depot-specific analysis reveals a class of adipocyte progenitors unique to visceral adipose tissue, which shares common features with beige preadipocytes. Our human single-cell transcriptome atlas across fat depots provides a resource to dissect functional genomics of metabolic disease.

OBJECTIVES: The outcome of emergency medicine (EM) training is to produce physicians who can competently run an emergency department (ED) shift. However, there are few tools with supporting validity evidence specifically designed to assess multiple key competencies across an entire shift. The investigators developed and gathered validity evidence for a novel entrustment‐based tool to assess a resident’s ability to safely run an ED shift. METHODS: Through a nominal group technique, local and national stakeholders identified dimensions of performance that are reflective of a competent ED physician and are required to safely manage an ED shift. These were included as items in the Ottawa Emergency Department Shift Observation Tool (O‐EDShOT), and each item was scored using an entrustment‐based rating scale. The tool was implemented in 2018 at the University of Ottawa Department of Emergency Medicine, and quantitative data and qualitative feedback were collected over 6 months. RESULTS: A total of 1,141 forms were completed by 78 physicians for 45 residents. An analysis of variance demonstrated an effect of training level with statistically significant increases in mean O‐EDShOT scores with each subsequent postgraduate year (p

Background When a patient is incapable of making medical decisions for him- or herself, a substitute decision-maker makes choices according to the patient's previously expressed wishes, values and beliefs; however, little is known about public readiness to act as a substitute decision-maker in Canada. Our primary objective was to measure public self-reported preparedness to act as a substitute decision-maker, and explore the attitudes, barriers and enablers associated with preparedness. Methods From November 2017 to June 2018, we conducted a mixed-methods street intercept survey at 12 pedestrian areas in Ottawa, Ontario. We used descriptive statistics and logistic regression analysis to assess predictors of perceived preparedness to be a substitute decision-maker and determine support for high school education. We analyzed qualitative interview questions using inductive thematic analysis. Results Of the 626 eligible respondents, 196 refused to participate, leaving 430 participants (response rate 68.7%). A total of 404 surveys (94.0%) were fully complete with no missing data. The respondents were mostly female (243 [56.5%]) and residents of Ontario (364 [84.6%]). The average age was 33.9 years. Although 314 respondents (73.0%) felt prepared to be a substitute decision-maker, 194 (45.1%) reported never having had meaningful conversations with loved ones to understand their wishes in the event of critical illness. A total of 293 participants (68.1%) identified important barriers to feeling prepared. Most respondents (309 [71.9%]) agreed that high school students should learn about being a substitute decision-maker, citing age appropriateness, potential societal benefit and improved decision-making, while cautioning the need to respect different maturity levels, cultures and experiences. Interpretation he lack of conversation between loved ones reveals a gap between perceived and actual preparedness to be a substitute decision-maker for a loved one with a critical illness. The overall acceptability of high school education warrants further exploration.

To transition successfully into independent practice, newly graduated independent physicians (new "attendings") undergo a process of professional identity formation (PIF) as a clinician within a new community of practice (CoP). PIF is crafted by socialization within a CoP including transfer of tacit knowledge. While certain tacit knowledge is critical for professional identity, we understand little how it shapes PIF. We set out to describe the tacit knowledge acquired by new attendings within a CoP and how it contributes to PIF. Informed by constructivist grounded theory, we interviewed 23 new attendings about the tacit knowledge they acquired in early practice. Data collection and analysis occurred iteratively. We identified themes using constant comparative analysis and generated a theory that underwent member checking and feedback. Implicit standards from group culture imparted high expectations on new attendings and led to internal stress. New attendings also encountered a tacit code of conduct as behavioral elements of group culture. These elements created external conflict between new attendings and group members such as departmental colleagues, consulting physicians, and other health professionals. Depending on the support they received, new attendings responded to the stress and conflict in three ways: they doubted, adjusted, or avoided. These strategies molded their professional identity, and moved them towards or away from the CoP as they navigated their transition and PIF. We describe a novel theory of how tacit group culture shaped new attending physicians' professional identity in a new community of practice. Internal stress and external conflict occurred due to high expectations and tacit culture elements. New attendings' doubt, adjust, or avoid responses, shaped by support they received, in turn crafted their professional identity. Education leaders should prepare graduating trainees to navigate aspects of transition to independent practice successfully.