Publications by authors named "Meredith Young"

94 Publications

The impact of distance on post-ICU disability.

Aust Crit Care 2021 Jul 25. Epub 2021 Jul 25.

Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; Monash Partners Academic Health Science Centre, Australia. Electronic address:

Background: Nonurban residential living is associated with adverse outcomes for a number of chronic health conditions. However, it is unclear what effect it has amongst survivors of critical illness.

Objectives: The purpose of this study is to determine whether patients living greater than 50 km from the treating intensive care unit (ICU) have disability outcomes at 6 months that differ from people living within 50 km.

Methods: This was a multicentre, prospective cohort study conducted in five metropolitan ICUs. Participants were adults admitted to the ICU, who received >24 h of mechanical ventilation and survived to hospital discharge. In a secondary analysis of these data, the cohort was dichotomised based on residential distance from the treating ICU: <50 km and ≥50 km. The primary outcome was patient-reported disability using the 12-item World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This was recorded at 6 months after ICU admission by telephone interview. Secondary outcomes included health status as measured by EQ-5D-5L return to work and psychological function as measured by the Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression was used to assess the association between distance from the ICU and moderate to severe disability, adjusted for potential confounders. Variables included in the multivariable model were deemed to be clinically relevant and had baseline imbalance between groups (p < 0.10). These included marital status and hours of mechanical ventilation. Sensitivity analysis was also conducted using distance in kilometres as a continuous variable.

Results: A total of 262 patients were enrolled, and 169 (65%) lived within 50 km of the treating ICU and 93 (35%) lived ≥50 km from the treating ICU (interquartile range [IQR] 10-664 km). There was no difference in patient-reported disability at 6 months between patients living <50 km and those living ≥50 km (WHODAS total disability % [IQR] 10.4 [2.08-25] v 14.6 [2.08-20.8], P = 0.74). There was also no difference between groups for the six major life domains of the WHODAS. There was no difference in rates of anxiety or depression as measured by HADS score (HADS anxiety median [IQR] 4 [1-7] v 3 [1-7], P = 0.60) (HADS depression median [IQR] 3 [1-6] v 3 [1-6], P = 0.62); health status as measured by EQ-5D (mean [SD] 66.7 [20] v 69.8 [22.2], P = 0.24); or health-related unemployment (% (N) 39 [26] v 25 [29.1], P = 0.61). After adjusting for confounders, living ≥50 km from the treating ICU was not associated with increased disability (odds ratio 0.61, 95% confidence interval: 0.33-1.16; P = 0.13) CONCLUSIONS: Survivors of intensive care in Victoria, Australia, who live at least 50 km from the treating ICU did not have greater disability than people living less than 50 km at 6 months after discharge. Living 50 km or more from the treating ICU was not associated with disability, nor was it associated with anxiety or depression, health status, or unemployment due to health.
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http://dx.doi.org/10.1016/j.aucc.2021.05.013DOI Listing
July 2021

Decontamination effectiveness and the necessity of innovation in a large-scale disaster simulation.

Am J Disaster Med 2021 Winter;16(1):67-73

Associate Professor, Institute of Health Sciences Education and Department of Medicine, McGill University, Montreal, Canada.

Background: Chemical, biological, radiologic, nuclear, and explosive (CBRNE) events threaten the health and integrity of human populations across the globe. Effective decontamination is a central component of CBRNE disaster response.

Objective: This paper provides an objective determination of wet decontamination effectiveness through the use of a liquid-based contaminant proxy and describes the mobilization and adaptation of easily available materials for the needs of decontamination in pediatric victims.

Methods: In this in-situ disaster simulation conducted at a pediatric hospital, decontamination effectiveness was determined through a liquid-based contaminant proxy, and standard burn charts to systematically estimate affected total body surface area (TBSA) in 39 adult simulated patients. Two independent raters evaluated TBSA covered by the contaminant before and after decontamination.

Results: On average, simulated patients had 59 percent (95 percent CI [53, 65]) of their TBSA covered by the simulated contaminant prior to decontamination. Following a wet decontamination protocol, the average reduction in TBSA contamination was 81 percent (95 percent CI [74, 88]). There was high inter-rater reliability for TBSA assessment (intraclass correlation coefficient = 0.83, 95 percent CI [0.68, 0.92]. A modified infant bath was tested during the simulated decontamination of infant mannequins and thereafter integrated to the local protocol.

Conclusion: Wet decontamination can remove more than 80 percent of the initial contaminant found on adult simulated patients. The use of a liquid-based visual tool as a contaminant proxy enables the inexpensive evaluation of decontamination performance in a simulated setting. This paper also describes an innovative, low-cost adaptation of a local decontamination protocol to better meet pediatric needs.
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http://dx.doi.org/10.5055/ajdm.2021.0388DOI Listing
May 2021

"It's a Big Part of Being Good Surgeons": Surgical Trainees' Perceptions of Error Recovery in the Operating Room.

J Surg Educ 2021 Apr 19. Epub 2021 Apr 19.

Institute for Health Sciences Education, McGill University, Montreal, Quebec, Canada; Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada. Electronic address:

Background: The burden of surgical error is high - errors threaten patient safety, lead to increased economic costs to society, and contribute to physician and resident burnout. To date, the majority of work has focused on strategies for reducing the incidence of surgical error, however, total error eradication remains unrealistic. Errors are, to some extent, unavoidable. Adequate preparation for practice should include optimal ways to manage and recover from errors; yet, these skills are rarely taught or assessed.

Objectives: This study aims to explore residents' perceptions and experiences of surgical error recovery. More specifically, we documented participant definitions of error recovery, and explored factors that were perceived to influence error recovery experiences and training in the operating room.

Method: Guided by a qualitative descriptive approach, we conducted semi-structured interviews with residents and fellows in surgical specialties in Canada and the United States. Purposive and snowball sampling were used to recruit residents and fellows in postgraduate year 1 to 5. Interviews were transcribed, analyzed and inductively coded.

Results: A total of 15 residents and fellows participated. When exploring the importance of error recovery for the trainees, competency and safety emerged as main themes, with error recovery being considered an indicator of overall surgical competency. Data concerning factors perceived to influence error recovery training were grouped under 4 major themes: (1) supervision (supervisor-related factors such as attending behaviors and reactions to errors), (2) self (factors such as self-assessed competency), (3) surgical context (factors related to the specific surgery or patient), and (4) situation safeness. Situational safeness was identified as a transversal theme describing factors to be considered when balancing between patient safety and the learning benefits of error recovery training.

Conclusion: Error recovery was considered to be an important skill for safe surgical practice and was considered an important educational target for learners during surgical training. Trainees' opportunities to learn to recover from technical errors in the OR are perceived to be influenced by several factors, leading to variable experiences and inconsistent opportunities to practice error recovery skills. Focusing on factors related to "supervision," "self," "surgery," and "situational safeness" may be an initial framework on which to build initial educational interventions to support the development of error recovery skills to better support safe surgical practice.
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http://dx.doi.org/10.1016/j.jsurg.2021.03.015DOI Listing
April 2021

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

JAMA 2020 10;324(13):1317-1329

School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

Design, Setting, And Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

Main Outcomes And Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

Conclusions And Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

Trial Registration: ClinicalTrials.gov Identifier: NCT02735707.
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http://dx.doi.org/10.1001/jama.2020.17022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489418PMC
October 2020

Learner handover: Perspectives and recommendations from the front-line.

Perspect Med Educ 2020 10;9(5):294-301

Department of General Practice, Université de Liège, Liège, Belgium.

Introduction: Current medical education models increasingly rely on longitudinal assessments to document learner progress over time. This longitudinal focus has re-kindled discussion regarding learner handover-where assessments are shared across supervisors, rotations, and educational phases, to support learner growth and ease transitions. The authors explored the opinions of, experiences with, and recommendations for successful implementation of learner handover among clinical supervisors.

Methods: Clinical supervisors from five postgraduate medical education programs at one institution completed an online questionnaire exploring their views regarding learner handover, specifically: potential benefits, risks, and suggestions for implementation. Survey items included open-ended and numerical responses. The authors used an inductive content analysis approach to analyze the open-ended questionnaire responses, and descriptive and correlational analyses for numerical data.

Results: Seventy-two participants completed the questionnaire. Their perspectives varied widely. Suggested benefits of learner handover included tailored learning, improved assessments, and enhanced patient safety. The main reported risk was the potential for learner handover to bias supervisors' perceptions of learners, thereby affecting the validity of future assessments and influencing the learner's educational opportunities and well-being. Participants' suggestions for implementation focused on who should be involved, when and for whom it should occur, and the content that should be shared.

Discussion: The diverse opinions of, and recommendations for, learner handover highlight the necessity for handover to maximize learning potential while minimizing potential harms. Supervisors' suggestions for handover implementation reveal tensions between assessment-of and for-learning.
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http://dx.doi.org/10.1007/s40037-020-00601-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7550510PMC
October 2020

Sound Practices: An Exploratory Study of Building and Monitoring Multiple-Choice Exams at Canadian Undergraduate Medical Education Programs.

Acad Med 2021 02;96(2):271-277

L. Varpio is professor of medicine and associate director of research, Health Professions Education graduate degree program, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0002-1412-4341.

Purpose: Written examinations such as multiple-choice question (MCQ) exams are a key assessment strategy in health professions education (HPE), frequently used to provide feedback, to determine competency, or for licensure decisions. However, traditional psychometric approaches for monitoring the quality of written exams, defined as items that are discriminant and contribute to increase the overall reliability and validity of the exam scores, usually warrant larger samples than are typically available in HPE contexts. The authors conducted a descriptive exploratory study to document how undergraduate medical education (UME) programs ensure the quality of their written exams, particularly MCQs.

Method: Using a qualitative descriptive methodology, the authors conducted semistructured interviews with 16 key informants from 10 Canadian UME programs in 2018. Interviews were transcribed, anonymized, coded by the primary investigator, and co-coded by a second team member. Data collection and analysis were conducted iteratively. Research team members engaged in analysis across phases, and consensus was reached on the interpretation of findings via group discussion.

Results: Participants focused their answers around MCQ-related practices, reporting using several indicators of quality such as alignment between items and course objectives and psychometric properties (difficulty and discrimination). The authors clustered findings around 5 main themes: processes for creating MCQ exams, processes for building quality MCQ exams, processes for monitoring the quality of MCQ exams, motivation to build quality MCQ exams, and suggestions for improving processes.

Conclusions: Participants reported engaging multiple strategies to ensure the quality of MCQ exams. Assessment quality considerations were integrated throughout the development and validation phases, reflecting recent work regarding validity as a social imperative.
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http://dx.doi.org/10.1097/ACM.0000000000003659DOI Listing
February 2021

Surgical Errors Happen, but Are Learners Trained to Recover from Them? A Survey of North American Surgical Residents and Fellows.

J Surg Educ 2020 Nov - Dec;77(6):1552-1561. Epub 2020 Jul 18.

Department of Experimental Surgery, McGill University, Montreal, Quebec, Canada; Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada; Institute of Health Sciences Education, McGill University, Montreal, Quebec, Canada. Electronic address:

Background: Surgical training necessitates graded supervision and supported independence in order to reach competence. In developing surgical skills, trainees can, and will, make mistakes. A key skill required for independent practice is the ability to recover from an error or unexpected complication. Error recovery includes recognizing and managing a technical error in order to ensure patient safety and may be underrepresented in current educational approaches.

Objective: The purpose of this study is to explore residents' experiences and perceptions of error recovery training in surgical procedures.

Method: An online survey was sent to surgical program directors in the United States and Canada using the Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada distribution lists. Participating programs distributed the survey to their residents and fellows. The survey was composed of Likert-scale items, yes/no questions as well as open-ended questions focused on perceptions, experiences, and factors that influence to error recovery training in the operating room.

Results: A total of 206 surveys were completed. Overall, 99% (n = 203) agreed or strongly agreed that error recovery is an important competency for future practice. This was reflected in free-text response: "Errors can be minimized but they are inevitable, so certainly believe a surgical curriculum that addresses error recovery is of paramount importance." While 83% (n = 170) feel confident recovering from minor errors, only 34% (n = 68) feel confident that they could recover from major errors that are likely to have serious consequences on patient safety. Overall, residents do not consider that they have adequate training in error recovery, with only 37% (n = 72) felt they were adequately trained to recover from major errors. It was also mentioned "The quality of learning regarding error recovery depends entirely on the attending."

Conclusions: Opportunities to learn to recover from technical errors in the operating room are valued by surgical trainees, but they perceive their training to be both inadequate and variable. This contributes to a lack of confidence in error recovery skills throughout their surgical training. There is a need to explore how best to integrate error recovery into more formal surgical curricula in order to better support learners and, ultimately, contribute to increased surgical safety.
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http://dx.doi.org/10.1016/j.jsurg.2020.05.031DOI Listing
June 2021

Does Educational Handover Influence Subsequent Assessment?

Acad Med 2021 01;96(1):118-125

M. Young is associate professor, Institute of Health Sciences Education and Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; ORCID: http://orcid.org/0000-0002-2036-2119.

Purpose: Educational handover (i.e., providing information about learners' past performance) is controversial. Proponents argue handover could help tailor learning opportunities. Opponents fear it could bias subsequent assessments and lead to self-fulfilling prophecies. This study examined whether raters provided with reports describing learners' minor weaknesses would generate different assessment scores or narrative comments than those who did not receive such reports.

Method: In this 2018 mixed-methods, randomized, controlled, experimental study, clinical supervisors from 5 postgraduate (residency) programs were randomized into 3 groups receiving no educational handover (control), educational handover describing weaknesses in medical expertise, and educational handover describing weaknesses in communication. All participants watched the same videos of 2 simulated resident-patient encounters and assessed performance using a shortened mini-clinical evaluation exercise form. The authors compared mean scores, percentages of negative comments, comments focusing on medical expertise, and comments focusing on communication across experimental groups using analyses of variance. They examined potential moderating effects of supervisor experience, gender, and mindsets (fixed vs growth).

Results: Seventy-two supervisors participated. There was no effect of handover report on assessment scores (F(2, 69) = 0.31, P = .74) or percentage of negative comments (F(2, 60) = 0.33, P = .72). Participants who received a report indicating weaknesses in communication generated a higher percentage of comments on communication than the control group (63% vs 50%, P = .03). Participants who received a report indicating weaknesses in medical expertise generated a similar percentage of comments on expertise compared to the controls (46% vs 47%, P = .98).

Conclusions: This study provides initial empirical data about the effects of educational handover and suggests it can-in some circumstances-lead to more targeted feedback without influencing scores. Further studies are required to examine the influence of reports for a variety of performance levels, areas of weakness, and learners.
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http://dx.doi.org/10.1097/ACM.0000000000003528DOI Listing
January 2021

Postpositivism in Health Professions Education Scholarship.

Acad Med 2020 05;95(5):695-699

M.E. Young is associate professor, Institute of Health Sciences Education and Department of Medicine, McGill University, Montreal, Quebec, Canada; ORCID: http://orcid.org/0000-0002-2036-2119. A. Ryan is associate professor and director of assessment, Department of Medical Education, Melbourne Medical School, University of Melbourne, Melbourne, Australia; ORCID: https://orcid.org/0000-0002-0480-5522.

An understanding of the diversity of perspectives within the research paradigms of health professions education (HPE) is essential for rigorous research design and more purposeful engagement with the contributions of others. In this article, the authors explicitly discuss the underlying assumptions, notions of good scholarship, and shortcomings of the postpositivism research paradigm. While postpositivism is likely one of the more familiar paradigms within HPE research, it is rarely formally or explicitly described. Drawing on key literature and contemporary examples, the authors describe the ontology, epistemology, methodologies, axiology, signs of rigor, and common critiques of postpositivism. A case study provides the focus for a practical illustration of how a postpositivist approach to education research could be applied. Suggestions for further reading are provided for those who are keen to delve deeper into the history and key tenants of the postpositivist stance.
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http://dx.doi.org/10.1097/ACM.0000000000003089DOI Listing
May 2020

Mapping clinical reasoning literature across the health professions: a scoping review.

BMC Med Educ 2020 Apr 7;20(1):107. Epub 2020 Apr 7.

Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.

Background: Clinical reasoning is at the core of health professionals' practice. A mapping of what constitutes clinical reasoning could support the teaching, development, and assessment of clinical reasoning across the health professions.

Methods: We conducted a scoping study to map the literature on clinical reasoning across health professions literature in the context of a larger Best Evidence Medical Education (BEME) review on clinical reasoning assessment. Seven databases were searched using subheadings and terms relating to clinical reasoning, assessment, and Health Professions. Data analysis focused on a comprehensive analysis of bibliometric characteristics and the use of varied terminology to refer to clinical reasoning.

Results: Literature identified: 625 papers spanning 47 years (1968-2014), in 155 journals, from 544 first authors, across eighteen Health Professions. Thirty-seven percent of papers used the term clinical reasoning; and 110 other terms referring to the concept of clinical reasoning were identified. Consensus on the categorization of terms was reached for 65 terms across six different categories: reasoning skills, reasoning performance, reasoning process, outcome of reasoning, context of reasoning, and purpose/goal of reasoning. Categories of terminology used differed across Health Professions and publication types.

Discussion: Many diverse terms were present and were used differently across literature contexts. These terms likely reflect different operationalisations, or conceptualizations, of clinical reasoning as well as the complex, multi-dimensional nature of this concept. We advise authors to make the intended meaning of 'clinical reasoning' and associated terms in their work explicit in order to facilitate teaching, assessment, and research communication.
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http://dx.doi.org/10.1186/s12909-020-02012-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140328PMC
April 2020

Being Edgy in Health Professions Education: Concluding the Philosophy of Science Series.

Acad Med 2020 07;95(7):995-998

A. MacLeod is professor and director of education research in continuing professional development, Faculty of Medicine, Dalhousie University, Halifax, Canada. R.H. Ellaway is professor, Department of Community Health Sciences, and director, Office of Health and Medical Education Scholarship, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. E. Paradis is assistant professor, status-only, University of Toronto, and a scientist, Wilson Centre, Toronto, Ontario, Canada. Y.S. Park is associate professor and associate head, Department of Medical Education and Director of Research, Office of Educational Affairs, University of Illinois College of Medicine, Chicago, Illinois. M. Young is associate professor, Institute of Health Sciences Education, McGill University, Montreal, Quebec, Canada. L. Varpio is professor, Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

The philosophy of science is concerned with what science is, its conceptual framing and underlying logic, and its ability to generate meaningful and useful knowledge. To that end, concepts such as ontology (what exists and in what way), epistemology (the knowledge we use or generate), and axiology (the value of things) are important if somewhat neglected topics in health professions education scholarship. In an attempt to address this gap, Academic Medicine has published a series of Invited Commentaries on topics in the philosophy of science germane to health professions educational science. This Invited Commentary concludes the Philosophy of Science series by providing a summary of the key concepts that were elucidated over the course of the series, highlighting the intent of the series and the principles of ontology, epistemology, axiology, and methodology. The authors conclude the series with a discussion of the benefits and challenges of cross-paradigmatic research.
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http://dx.doi.org/10.1097/ACM.0000000000003250DOI Listing
July 2020

Nudging clinical supervisors to provide better in-training assessment reports.

Perspect Med Educ 2020 02;9(1):66-70

Department of Medicine and Institute of Health Sciences Education; Faculty of Medicine, McGill University, Montreal, QC, Canada.

Introduction: In-training assessment reports (ITARs) summarize assessment during a clinical placement to inform decision-making and provide formal feedback to learners. Faculty development is an effective but resource-intensive means of improving the quality of completed ITARs. We examined whether the quality of completed ITARs could be improved by 'nudges' from the format of ITAR forms.

Methods: Our first intervention consisted of placing the section for narrative comments at the beginning of the form, and using prompts for recommendations (Do more, Keep doing, Do less, Stop doing). In a second intervention, we provided a hyperlink to a detailed assessment rubric and shortened the checklist section. We analyzed a sample of 360 de-identified completed ITARs from six disciplines across the three academic years where the different versions of the ITAR were used. Two raters independently scored the ITARs using the Completed Clinical Evaluation Report Rating (CCERR) scale. We tested for differences between versions of the ITAR forms using a one-way ANOVA for the total CCERR score, and MANOVA for the nine CCERR item scores.

Results: Changes to the form structure (nudges) improved the quality of information generated as measured by the CCERR instrument, from a total score of 18.0/45 (SD 2.6) to 18.9/45 (SD 3.1) and 18.8/45 (SD 2.6), p = 0.04. Specifically, comments were more balanced, more detailed, and more actionable compared with the original ITAR.

Discussion: Nudge interventions, which are inexpensive and feasible, should be included in multipronged approaches to improve the quality of assessment reports.
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http://dx.doi.org/10.1007/s40037-019-00554-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012977PMC
February 2020

The Spectrum of Inductive and Deductive Research Approaches Using Quantitative and Qualitative Data.

Acad Med 2020 07;95(7):1122

associate professor, Institute of Health Sciences Education and Department of Medicine, McGill University professor, Department of Medicine, Uniformed Services University of the Health Sciences professor, Department of Medicine, Uniformed Services University of the Health Sciences assistant professor and Canada Research Chair, Collaborative Healthcare Practice, The Wilson Centre, University Health Network, Leslie Dan Faculty of Pharmacy and Department of Sociology, University of Toronto.

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http://dx.doi.org/10.1097/ACM.0000000000003101DOI Listing
July 2020

The utility of failure: a taxonomy for research and scholarship.

Authors:
Meredith Young

Perspect Med Educ 2019 12;8(6):365-371

Department of Medicine and Institute for Health Sciences Education, McGill University, Montreal, QC, Canada.

Introduction: Health professions education (HPE) research and scholarship utilizes a range of methodologies, traditions, and disciplines. Many conducting scholarship in HPE may not have had the opportunity to consider the value of a well-designed but failed scholarly project, benefitted from role-modelling of the value of failure, nor have engaged with the common nature of failure in research and scholarship.

Methods: Drawing on key concepts from philosophy of science, this piece describes the necessity and benefit of failure in research and scholarship, presents a taxonomy of failure relevant to HPE research, and applies this taxonomy to works published in the Perspectives on Medical Education failures/surprises series.

Results: I propose three forms of failure relevant to HPE scholarship: innovation-driven, discovery-oriented, and serendipitous failure. Innovation-driven failure was the most commonly represented type of failure in the failures/surprises section, and discovery-oriented the least common.

Conclusions: Considering failure in research and scholarship, four conclusions are drawn. First, failure is integral to research and scholarship-it is how theories are refined, discoveries are made, and innovations are developed. Second, we must purposefully engage with the opportunities that failure provide-understanding why a particular well-designed project failed is an opportunity for further insight. Third, we must engage publicly with failure in order to better communicate and role model the complexities of executing scholarship or innovating in HPE. Fourth, in order to make failure truly an opportunity for growth, we must, as a community, humanize and normalize failure as part of a productive scholarly approach.
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http://dx.doi.org/10.1007/s40037-019-00551-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6904373PMC
December 2019

Scoping reviews in health professions education: challenges, considerations and lessons learned about epistemology and methodology.

Adv Health Sci Educ Theory Pract 2020 10 25;25(4):989-1002. Epub 2019 Nov 25.

Institute of Health Sciences Education, McGill University, Montreal, QC, Canada.

Scoping reviews are increasingly used in health professions education to synthesize research and scholarship, and to report on the depth and breadth of the literature on a given topic. In this Perspective, we argue that the philosophical stance scholars adopt during the execution of a scoping review, including the meaning they attribute to fundamental concepts such as knowledge and evidence, influences how they gather, analyze, and interpret information obtained from a heterogeneous body of literature. We highlight the principles informing scoping reviews and outline how epistemology-the aspect of philosophy that "deals with questions involving the nature of knowledge, the justification of beliefs, and rationality"-should guide methodological considerations, toward the aim of ensuring the production of a high-quality review with defensible and appropriate conclusions. To contextualize our claims, we illustrate some of the methodological challenges we have personally encountered while executing a scoping review on clinical reasoning and reflect on how these challenges could have been reconciled through a broader understanding of the methodology's philosophical foundation. We conclude with a description of lessons we have learned that might usefully inform other scholars who are considering undertaking a scoping review in their own domains of inquiry.
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http://dx.doi.org/10.1007/s10459-019-09932-2DOI Listing
October 2020

The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework.

Acad Med 2020 07;95(7):989-994

L. Varpio is professor and associate director of research, Graduate Programs in Health Professions Education in the Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0002-1412-4341. E. Paradis is assistant professor, University of Toronto, Toronto, Ontario, Canada, scientist, Wilson Centre, Toronto, Ontario, Canada, and researcher, Facebook, Menlo Park, California; ORCID: https://orcid.org/0000-0001-9103-4721. S. Uijtdehaage is professor and associate director, Graduate Programs in Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0001-8598-4683. M. Young is associate professor, Institute of Health Sciences Education, McGill University, Montreal, Quebec, Canada; ORCID: http://orcid.org/0000-0002-2036-2119.

Health professions education (HPE) researchers are regularly asked to articulate their use of theory, theoretical frameworks, and conceptual frameworks in their research. However, all too often, these words are used interchangeably or without a clear understanding of the differences between these concepts. Further problematizing this situation is the fact that theory, theoretical framework, and conceptual framework are terms that are used in different ways in different research approaches. In this article, the authors set out to clarify the meaning of these terms and to describe how they are used in 2 approaches to research commonly used in HPE: the objectivist deductive approach (from theory to data) and the subjectivist inductive approach (from data to theory). In addition to this, given that within subjectivist inductive research theory, theoretical framework, and conceptual framework can be used in different ways, they describe 3 uses that HPE researchers frequently rely on: fully inductive theory development, fully theory-informed inductive, and theory-informing inductive data analysis.
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July 2020

The Effect of Foregrounding Intended Use on Observers' Ratings and Comments in the Assessment of Clinical Competence.

Acad Med 2020 05;95(5):777-785

W. Tavares is assistant professor and scientist, The Wilson Centre, and Post-MD Education, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0001-8267-9448. M. Young is associate professor, Department of Medicine, McGill University, Montreal, Quebec, Canada; ORCID: https://orcid.org/0000-0002-2036-2119. G. Gauthier is adjunct professor, Medecine Interne, Université de Sherbrooke, Sherbrooke, Quebec, Canada; ORCID: https://orcid.org/0000-0001-7368-638X. C. St-Onge is professor, Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada; ORCID: http://orcid.org/0000-0001-5313-0456.

Purpose: Some educational programs have adopted the premise that the same assessment can serve both formative and summative goals; however, how observers understand and integrate the intended uses of assessment may affect the way they execute the assessment task. The objective of this study was to explore the effect of foregrounding a different intended use (formative vs summative learner assessment) on observer contributions (ratings and comments).

Method: In this randomized, experimental, between-groups, mixed-methods study (May-September 2017), participants observed 3 prerecorded clinical performances under formative or summative assessment conditions. Participants rated performances using a global rating tool and provided comments. Participants were then asked to reconsider their ratings from the alternative perspective (from which they were originally blinded). They received the opportunity to alter their ratings and comments and to provide rationales for their decision to change or preserve their original ratings and comments. Outcomes included participant-observers' comments, ratings, changes to each, and stated rationales for changing or preserving their contributions.

Results: Foregrounding different intended uses of assessment data for participant-observers did not result in differences in ratings, number or type of comments (both emphasized evaluative over constructive statements), or the ability to differentiate among performances. After adopting the alternative perspective, participant-observers made only small changes in ratings or comments. Participant-observers reported that they engage in the process in an evaluative manner despite different intended uses.

Conclusions: Foregrounding different intended uses for assessments did not result in significant systematic differences in the assessment data generated. Observers provided more evaluative than constructive statements overall, regardless of the intended use of the assessment. Future research is needed to explore whether these results hold in social/workplace-based contexts and how they might affect learners.
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May 2020

How Consistent Is Competent? Examining Variance in Psychomotor Skills Assessment.

Acad Med 2020 05;95(5):771-776

M. Labbé is a resident, Department of Family Medicine, McGill University, Montreal, Quebec, Canada. M. Young is associate professor, Faculty of Medicine, McGill University, and research scientist, Centre for Medical Education, McGill University, Montreal, Quebec, Canada. M. Mascarella is a resident, Department of Otolaryngology-Head and Neck Surgery, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada. M. Husein is associate professor, Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada. P.C. Doyle is professor, Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada. L.H.P. Nguyen is associate professor, Department of Otolaryngology-Head and Neck Surgery, McGill University, and member, Centre for Medical Education, McGill University, Montreal, Quebec, Canada.

Purpose: Direct assessment of trainee performance across time is a core tenet of competency-based medical education. Unlike variability of psychomotor skills across levels of expertise, performance variability exhibited by a particular trainee across time remains unexplored. The goal of this study was to document the consistency of individual surgeons' technical skill performance.

Method: A secondary analysis of assessment data (collected in 2010-2012, originally published in 2015) generated by a prospective cohort of participants at Montreal Children's Hospital with differing levels of expertise was conducted in 2017. Trained raters scored blinded recordings of a myringotomy and tube insertion performed 4 times by junior and senior residents and attending surgeons over a 6-month period using a previously reported assessment tool. Descriptive exploratory analyses and univariate comparison of standard deviations (SDs) were conducted to document variability within individuals across time and across training levels.

Results: Thirty-six assessments from 9 participants were analyzed. The SD of scores for junior residents was highly variable (5.8 out of a scale of 30 compared with 1.8 for both senior residents and attendings [F(2,19) = 5.68, P < 0.05]). For a given individual, the range of scores was twice as large for junior residents than for senior residents and attendings.

Conclusions: Surgical residents may display highly variable performances across time, and individual variability appears to decrease with increasing expertise. Operative skill variability could be underrepresented in direct observation assessment; emphasis on an adequate amount of repetitive evaluations for junior residents may be needed to support judgments of competence or entrustment.
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May 2020

A Scoping Review of Physicians' Clinical Reasoning in Emergency Departments.

Ann Emerg Med 2020 02 29;75(2):206-217. Epub 2019 Aug 29.

Centre for Medical Education, McGill University, Montreal, Quebec, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada; Institut de Recherche Santé et Société, Université catholique de Louvain, Brussels, Belgium.

Study Objective: Clinical reasoning is considered a core competency of physicians. Yet there is a paucity of research on clinical reasoning specifically in emergency medicine, as highlighted in the literature.

Methods: We conducted a scoping review to examine the state of research on clinical reasoning in this specialty. Our team, composed of content and methodological experts, identified 3,763 articles in the literature, 95 of which were included.

Results: Most studies were published after 2000. Few studies focused on the cognitive processes involved in decisionmaking (ie, clinical reasoning). Of these, many confirmed findings from the general literature on clinical reasoning; specifically, the role of both intuitive and analytic processes. We categorized factors that influence decisionmaking into contextual, patient, and physician factors. Many studies focused on decisions in regard to investigations and admission. Test ordering is influenced by physicians' experience, fear of litigation, and concerns about malpractice. Fear of litigation and malpractice also increases physicians' propensity to admit patients. Context influences reasoning but findings pertaining to specific factors, such as patient flow and workload, were inconsistent.

Conclusion: Many studies used designs such as descriptive or correlational methods, limiting the strength of findings. Many gray areas persist, in which studies are either scarce or yield conflicting results. The findings of this scoping review should encourage us to intensify research in the field of emergency physicians' clinical reasoning, particularly on the cognitive processes at play and the factors influencing them, using appropriate theoretical frameworks and more robust methods.
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http://dx.doi.org/10.1016/j.annemergmed.2019.06.023DOI Listing
February 2020

Focal Length Fluidity: Research Questions in Medical Education Research and Scholarship.

Acad Med 2019 11;94(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 58th Annual Research in Medical Education Sessions):S1-S4

M. Young is associate professor, Department of Medicine and Institute for Health Sciences Education, McGill University, Montreal, Quebec, Canada. K. LaDonna is assistant professor, Department of Innovation in Medical Education and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada. L. Varpio is professor, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. D.F. Balmer is associate professor, Department of Pediatrics, The Children's Hospital of Pennsylvania and University of Pennsylvania, Philadelphia, Pennsylvania.

Research and scholarship in health professions education has been shaped by intended audience (i.e., producers vs users) and the purpose of research questions (i.e., curiosity driven or service oriented), but these archetypal dichotomies do not represent the breadth of scholarship in the field. Akin to an array of lenses required by scientists to capture images of a black hole, the authors propose the analogy of lenses with different focal lengths to consider how different kinds of research questions can offer insight into health professions research-a microscope, a magnifying glass, binoculars, and telescopes allow us to ask and answer different kinds of research questions. They argue for the relevance of all of the different kinds of research questions (or focal lengths); each provides important insight into a particular phenomenon and contributes to understanding that phenomenon in a different way. The authors propose that research questions can move fluidly across focal lengths. For example, a theoretical question can be made more pragmatic through asking "how" questions ("How can we observe and measure a phenomenon?"), whereas a pragmatic question can be made more theoretic by asking a series of "why" questions ("Why are these findings relevant to larger issues?"). In summary, only through the combination of lenses with different focal lengths, brought to bear through interdisciplinary work, can we fully comprehend important phenomena in health professions education and scholarship-the same way scientists managed to image a black hole.
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http://dx.doi.org/10.1097/ACM.0000000000002913DOI Listing
November 2019

Maximal Recruitment Open Lung Ventilation in Acute Respiratory Distress Syndrome (PHARLAP). A Phase II, Multicenter Randomized Controlled Clinical Trial.

Am J Respir Crit Care Med 2019 12;200(11):1363-1372

Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.

Open lung ventilation strategies have been recommended in patients with acute respiratory distress syndrome (ARDS). To determine whether a maximal lung recruitment strategy reduces ventilator-free days in patients with ARDS. A phase II, multicenter randomized controlled trial in adults with moderate to severe ARDS. Patients received maximal lung recruitment, titrated positive end expiratory pressure and further Vt limitation, or control "protective" ventilation. The primary outcome was ventilator-free days at Day 28. Secondary outcomes included mortality, barotrauma, new use of hypoxemic adjuvant therapies, and ICU and hospital stay. Enrollment halted October 2, 2017, after publication of ART (Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial), when 115 of a planned 340 patients had been randomized (57% male; mean age, 53.6 yr). At 28 days after randomization, there was no difference between the maximal lung recruitment and control ventilation strategies in ventilator-free days (median, 16 d [interquartile range (IQR), 0-21 d],  = 57, vs. 14.5 d [IQR, 0-21.5 d],  = 56;  = 0.95), mortality (24.6% [ = 14/56] vs. 26.8% [ = 15/56];  = 0.79), or the rate of barotrauma (5.2% [ = 3/57] vs. 10.7% [ = 6/56];  = 0.32). However, the intervention group showed reduced use of new hypoxemic adjuvant therapies (i.e., inhaled nitric oxide, extracorporeal membrane oxygenation, prone; median change from baseline 0 [IQR, 0-1] vs. 1 [IQR, 0-1];  = 0.004) and increased rates of new cardiac arrhythmia ( = 17 [29%] vs.  = 7 [13%];  = 0.03). Compared with control ventilation, maximal lung recruitment did not reduce the duration of ventilation-free days or mortality and was associated with increased cardiovascular adverse events but lower use of hypoxemic adjuvant therapies.Clinical trial registered with www.clinicaltrials.gov (NCT01667146).
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http://dx.doi.org/10.1164/rccm.201901-0109OCDOI Listing
December 2019

Examinee Cohort Size and Item Analysis Guidelines for Health Professions Education Programs: A Monte Carlo Simulation Study.

Acad Med 2020 01;95(1):151-156

A.-S. Aubin is professor, Département d'éducation et de pédagogie, Université du Québec à Montréal, Montréal, Québec, Canada. At the time of the study, he was a postdoctoral fellow, Chaire de recherche en pédagogie médicale Paul Grand'Maison de la Société des médecins de l'Université de Sherbrooke, Sherbrooke, Québec, Canada. M. Young is associate professor, Department of Medicine, and research scientist, Centre for Medical Education, McGill University, Montreal, Québec, Canada; ORCID: http://orcid.org/0000-0002-2036-2119. K. Eva is senior scientist, Centre for Health Education Scholarship, and professor, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; ORCID: https://orcid.org/0000-0002-8672-2500. C. St-Onge is professor, Department of Medicine, Faculty of Medicine and Health Sciences, and Chaire de recherche en pédagogie médicale Paul Grand'Maison de la Société des Médecins, Université de Sherbrooke, Sherbrooke, Québec, Canada; ORCID: https://orcid.org/0000-0001-5313-0456.

Purpose: Using item analyses is an important quality-monitoring strategy for written exams. Authors urge caution as statistics may be unstable with small cohorts, making application of guidelines potentially detrimental. Given the small cohorts common in health professions education, this study's aim was to determine the impact of cohort size on outcomes arising from the application of item analysis guidelines.

Method: The authors performed a Monte Carlo simulation study in fall 2015 to examine the impact of applying 2 commonly used item analysis guidelines on the proportion of items removed and overall exam reliability as a function of cohort size. Three variables were manipulated: Cohort size (6 levels), exam length (6 levels), and exam difficulty (3 levels). Study parameters were decided based on data provided by several Canadian medical schools.

Results: The analyses showed an increase in proportion of items removed with decreases in exam difficulty and decreases in cohort size. There was no effect of exam length on this outcome. Exam length had a greater impact on exam reliability than did cohort size after applying item analysis guidelines. That is, exam reliability decreased more with shorter exams than with smaller cohorts.

Conclusions: Although program directors and assessment creators have little control over their cohort sizes, they can control the length of their exams. Creating longer exams makes it possible to remove items without as much negative impact on the exam's reliability relative to shorter exams, thereby reducing the negative impact of small cohorts when applying item removal guidelines.
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http://dx.doi.org/10.1097/ACM.0000000000002888DOI Listing
January 2020

The terminology of clinical reasoning in health professions education: Implications and considerations.

Med Teach 2019 11 17;41(11):1277-1284. Epub 2019 Jul 17.

Uniformed Services, University of the Health Sciences , Bethesda , MD , USA.

Clinical reasoning is considered to be at the core of health practice. Here, we report on the diversity and inferred meanings of the terms used to refer to clinical reasoning and consider implications for teaching and assessment. In the context of a Best Evidence Medical Education (BEME) review of 625 papers drawn from 18 health professions, we identified 110 terms for clinical reasoning. We focus on iterative categorization of these terms across three phases of coding and considerations for how terminology influences educational practices. Following iterative coding with 5 team members, consensus was possible for 74, majority coding was possible for 16, and full team disagreement existed for 20 terms. Categories of terms included: purpose/goal of reasoning, outcome of reasoning, reasoning performance, reasoning processes, reasoning skills, and context of reasoning. Findings suggest that terms used in reference to clinical reasoning are non-synonymous, not uniformly understood, and the level of agreement differed across terms. If the language we use to describe, to teach, or to assess clinical reasoning is not similarly understood across clinical teachers, program directors, and learners, this could lead to confusion regarding what the educational or assessment targets are for "clinical reasoning."
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http://dx.doi.org/10.1080/0142159X.2019.1635686DOI Listing
November 2019

Aspiration therapy for the treatment of obesity: 4-year results of a multicenter randomized controlled trial.

Surg Obes Relat Dis 2019 Aug 2;15(8):1348-1354. Epub 2019 May 2.

University of Colorado Denver, Denver, Colorado.

Background: The AspireAssist is the first Food and Drug Administration-approved endoluminal device indicated for treatment of class II and III obesity.

Objectives: We earlier reported 1-year results of the PATHWAY study. Here, we report 4-year outcomes.

Setting: United States-based, 10-center, randomized controlled trial involving 171 participants with the treatment arm receiving Aspiration Therapy (AT) plus Lifestyle Therapy and the control arm receiving Lifestyle Therapy (2:1 randomization).

Methods: AT participants were permitted to continue in the study for an additional year up to a maximum of 5 years providing they maintained at least 10% total weight loss (TWL) from baseline at each year end. For AT participants who continued the study, 5 medical monitoring visits were provided at weeks 60, 68, 76, 90, and 104 and thereafter once every 13 weeks up to week 260. Exclusion criteria were a history of eating disorder or evidence of eating disorder on a validated questionnaire. Follow-up weight, quality of life, and co-morbidities were compared with the baseline levels. In addition, rates of serious adverse event, persistent fistula, withdrawal, and A-tube replacement were reported. All analyses were performed using a per-protocol analysis.

Results: Of the 82 AT participants who completed 1 year, 58 continued to this phase of the trial. Mean baseline body mass index of these 58 patients was 41.6 ± 4.5 kg/m. At the end of first year (at the beginning of the follow-up study), these 58 patients had a body mass index of 34.1 ± 5.4 kg/m and had achieved an 18.3 ± 8.0% TWL. On a per protocol basis, patients experienced 14.2%, 15.3%, 16.6%, and 18.7% TWL at 1, 2, 3, and 4 years, respectively (P < .01 for all). Forty of 58 patients (69%) achieved at least 10% TWL at 4 years or at time of study withdrawal. Improvements in quality of life scores and select cardiometabolic parameters were also maintained through 4 years. There were 2 serious adverse events reported in the second through fourth years, both of which resolved with removal or replacement of the A tube. Two persistent fistulas required surgical repair, representing approximately 2% of all tube removals. There were no clinically significant metabolic or electrolytes disorders observed, nor any evidence for development of any eating disorders.

Conclusions: The results of this midterm study have shown that AT is a safe, effective, and durable weight loss alternative for people with class II and III obesity and who are willing to commit to using the therapy and adhere to adjustments in eating behavior.
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August 2019

Managing the airway catastrophe: longitudinal simulation-based curriculum to teach airway management.

J Otolaryngol Head Neck Surg 2019 Feb 19;48(1):10. Epub 2019 Feb 19.

Centre for Medical Education, McGill University, Montreal, Canada.

Background: A longitudinal curriculum was developed in conjunction with anesthesiologists, otolaryngologists, emergency physicians and experts in medical simulation and education.

Methods: Residents participated in four different simulation-based training modules using animal models, cadavers, task trainers, and crisis scenarios using high fidelity manikins. Scenarios were based on various clinical settings (i.e. emergency room, operating room) and were followed by video-assisted structured debriefings. Participants completed both a self-assessment questionnaire and an exit survey using five-point Likert scales.

Results: 31 otolaryngology residents participated in the curriculum. Residents reported simulation training significantly improved technical skills such as tracheostomy, cricothyroidotomy and pediatric intubation (p < 0.05 for all). Non-technical skills, including communication, delegation and management were significantly improved on post-test surveys in simulated crisis scenarios (p < 0.05 for all). 90 (28/31) of participants found simulations to be very realistic. Junior residents placed increased value on didactic teaching and procedural skills, while senior residents on crisis scenarios. Survey results indicated that > 90% (28/31) of participants found the modules of the curriculum to be useful and would recommend them to others.

Conclusion: A longitudinal simulation-based medical curriculum can be an effective method to teach airway management and teamwork skills to otolaryngology residents.
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http://dx.doi.org/10.1186/s40463-019-0332-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381681PMC
February 2019

Ensuring the Quality of Multiple-Choice Tests: An Algorithm to Facilitate Decision Making for Difficult Questions.

Acad Med 2019 05;94(5):740

assistant professor, Department of Medicine and Centre for Medical Education assessment administrator, Undergraduate Medical Education assistant professor, Department of Medicine assistant professor, Department of Neurology & Neurosurgery and Centre for Medical Education associate professor, Department of Medicine and Centre for Medical Education associate professor, Department of Medicine and Centre for Medical Education, McGill University-All authors are members of the Student Assessment Subcommittee, Undergraduate Medical Education, McGill University.

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May 2019

Teaching communication skills to OTL-HNS residents: multisource feedback and simulated scenarios.

J Otolaryngol Head Neck Surg 2019 Jan 28;48(1). Epub 2019 Jan 28.

Department of Otolaryngology-Head and Neck Surgery, Montreal Children's Hospital, McGill University, 1001 boul. Decarie, A02.3015, Montreal, Quebec, H4A 3J1, Canada.

Background: Effective communication has been linked to a reduction in adverse events and improved patient compliance. Currently in Otolaryngology - Head and Neck Surgery (OTL-HNS) residency programs, there is limited explicit teaching of communication skills. Our objective was to implement an educational program on communication skills for residents using multisource assessment in several simulation-based contexts throughout residency.

Methods: For three consecutive years, OTL-HNS residents were recruited to participate in a total of nine simulation-based clinical scenarios in which communication skills could be honed. This educational program was designed to provide instruction and practice of challenging ethics scenarios, with communication efficacy as a secondary goal. To facilitate this goal, a multisource assessment was paired with a debriefing process that involved attending staff, observing and participating residents, standardized patients, and invited content experts.

Results: Seventeen residents completed the curriculum for at least two consecutive years from 2009 to 2011. The internal-consistency reliability of the scenarios ranged from 0.88 to 0.96. The intraclass correlation was 0.19, as expected in this context. There was no statistical difference in the mean ratings of performance across post-graduate year (PGY) level (p = 0.201). Results from the random-intercept regression indicated that, on average, a learner's mean rating at baseline was 3.6/5 and increased significantly by 0.25 points per year (p < 0.05) as assessed by OTL-HNS staff members and peers. No significant improvement across time was found for ratings by non-medical assessors.

Conclusion: Implementing an educational program focused on communication skills using a multisource assessment in various contexts has shown to be potentially effective at our institution, and resulted for yearly improvement and consolidation of performance of OTL-HNS residents as judged by faculty and residents. The inclusion of a multisource assessment in the simulation curriculum is key to allow for the representation of different perspectives on communication skills, for both the assessment and the debriefing process. Future studies are needed to explore the possibility of fully integrating this educational program into residence training in order to support deliberate communication skills teaching.
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http://dx.doi.org/10.1186/s40463-019-0329-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350291PMC
January 2019

Development and validation of a health profession education-focused scholarly mentorship assessment tool.

Perspect Med Educ 2019 02;8(1):43-46

Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.

Problem: PhD-trained researchers working in health professions education (HPE) regularly engage in one-on-one, or one-on-few, scholarly mentorship activities. While this work is often a formal expectation of these scientists' roles, rarely is there formal institutional acknowledgement of this mentorship. In fact, there are few official means through which a research scientist can document the frequency or quality of the scholarly mentorship they provide.

Approach: OUTCOMES: The STHPE assessment tool has appropriate psychometric properties and evidence supporting acceptability. It can be used to document areas of strength and areas for improvement for research scientists engaged in HPE-related scholarly mentorship.

Next Steps: At present, the STHPE assessment tool is the only formally developed tool for which there is evidence of validity for use by PhD-trained researchers working in HPE to collect feedback on their scholarly mentorship skills. The STPHE has been used in promotion and tenure packages to document effectiveness and quality of scholarly mentorship.
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http://dx.doi.org/10.1007/s40037-018-0491-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382618PMC
February 2019

Interdisciplinary Crisis Resource Management Training: How Do Otolaryngology Residents Compare? A Survey Study.

OTO Open 2018 Apr-Jun;2(2):2473974X18770409. Epub 2018 May 14.

Department of Otolaryngology-Head and Neck Surgery, McGill University, Montréal, Québec, Canada.

Objective: Emergent medical crises, such as acute airway obstruction, are often managed by interdisciplinary teams. However, resident training in crisis resource management traditionally occurs in silos. Our objective was to compare the current state of interdisciplinary crisis resource management (IDCRM) training of otolaryngology residents with other disciplines.

Methods: A survey study examining (1) the frequency with which residents are involved in interdisciplinary crises, (2) the current state of interdisciplinary training, and (3) the desired training was conducted targeting Canadian residents in the following disciplines: otolaryngology, anesthesiology, emergency medicine, general surgery, obstetrics and gynecology, internal medicine, pediatric emergency medicine, and pediatric/neonatal intensive care.

Results: A total of 474 surveys were completed (response rate, 12%). On average, residents were involved in 13 interdisciplinary crises per year. Only 8% of otolaryngology residents had access to IDCRM training, as opposed to 66% of anesthesiology residents. Otolaryngology residents reported receiving an average of 0.3 hours per year of interdisciplinary training, as compared with 5.4 hours per year for pediatric emergency medicine residents. Ninety-six percent of residents desired more IDCRM training, with 95% reporting a preference for simulation-based training.

Discussion: Residents reported participating in crises managed by interdisciplinary teams. There is strong interest in IDCRM and crisis resource management training; however, it is not uniformly available across Canadian residency programs. Despite their pivotal role in managing critical emergencies such as acute airway obstruction, otolaryngology residents received the least training.

Implication: IDCRM should be explicitly taught since it reflects reality and may positively affect patient outcomes.
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http://dx.doi.org/10.1177/2473974X18770409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239147PMC
May 2018

The challenges of detecting progress in generic competencies in the clinical setting.

Med Educ 2018 12;52(12):1259-1270

Centre for Medical Education, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.

Context: Competency-based medical education has spurred the implementation of longitudinal workplace-based assessment (WBA) programmes to track learners' development of competencies. These hinge on the appropriate use of assessment instruments by assessors. This study aimed to validate our assessment programme and specifically to explore whether assessors' beliefs and behaviours rendered the detection of progress possible.

Methods: We implemented a longitudinal WBA programme in the third year of a primarily rotation-based clerkship. The programme used the professionalism mini-evaluation exercise (P-MEX) to detect progress in generic competencies. We used mixed methods: a retrospective psychometric examination of student assessment data in one academic year, and a prospective focus group and interview study of assessors' beliefs and reported behaviours related to the assessment.

Results: We analysed 1662 assessment forms for 186 students. We conducted interviews and focus groups with 21 assessors from different professions and disciplines. Scores were excellent from the outset (3.5-3.7/4), with no meaningful increase across blocks (average overall scores: 3.6 in block 1 versus 3.7 in blocks 2 and 3; F = 8.310, d.f. 2, p < 0.001). The main source of variance was the forms (47%) and only 1% of variance was attributable to students, which led to low generalisability across forms (Eρ  = 0.18). Assessors reported using multiple observations to produce their assessments and were reluctant to harm students by consigning anything negative to writing. They justified the use of a consistent benchmark across time by citing the basic nature of the form or a belief that the 'competencies' assessed were in fact fixed attributes that were unlikely to change.

Conclusions: Assessors may purposefully deviate from instructions in order to meet their ethical standards of good assessment. Furthermore, generic competencies may be viewed as intrinsic and fixed rather than as learnable. Implementing a longitudinal WBA programme is complex and requires careful consideration of assessors' beliefs and values.
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http://dx.doi.org/10.1111/medu.13749DOI Listing
December 2018
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