Canadian General Surgery Residents Research Articles

Attitudes of Canadian general surgery staff and residents towards point-of-care ultrasound

Attitudes of Canadian general surgery staff and residents towards point-of-care ultrasound

Factors Associated With Resident Research Success: An Analysis of Canadian General Surgery Trainees

Better understanding the research productivity of Canadian general surgery residents and factors associated with success would provide a valuable reference and help inform actions to enable success. We aimed to characterize the research productivity of Canadian general surgery residents and to evaluate factors associated with residents' research quantity and impact. A cross-sectional, observational study was performed using publicly available data evaluating Canadian General Surgery resident research productivity. Research productivity was characterized using measures including publications per postgraduate year (PGY) and CiteScore among others. Residency programs were then comparatively assessed using a multivariable logistic regression to evaluate program and resident factors associated with achieving >50th percentile research productivity. All General Surgery residents from English speaking Canadian training programs were included in this study, which was completed at the University of Alberta, a tertiary level academic center in Edmonton, Canada. A wide range of resident research productivity was observed across Canada with the median publications per PGY of 0.29, and the median sum of a resident's publication CiteScores of 2.05. The median h-index was 0.90. Graduate degree completion and publication experience prior to residency were significantly associated with higher publications per PGY (OR 2.94 and OR 2.10, respectively), as well as higher mean CiteScore (OR 3.42 and 2.24). The program factors that were assessed, including program size, research blocks, mandatory projects, or higher staff research productivity, did not show significant association with increased research output. There is a wide range in research output by general surgery residents across the country. Successful completion of graduate degrees and the experience of publication prior to residency are associated with higher research productivity and impact.

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

The impact of COVID-19 on surgical education: perspectives from Canadian general surgery residents.

SummaryMost institutions have mitigated the impact of the COVID-19 pandemic on residency education by transitioning to web-based educational platforms and using innovative solutions, such as surgical video libraries, telehealth clinics, online question banks via social media platforms, and procedural simulations. Here, we assess the perceived impact of COVID-19 on Canadian surgical residency education and discuss the unique challenges in adapting to a virtual format and how novel training methods implemented during the pandemic may be useful in the future of surgical education.

Competency-based education in general surgery: Are Canadian residents ready?

SummaryCompetency-based education (CBE) is currently being implemented by the Royal College of Physicians and Surgeons of Canada across all residency programs. This shift away from time-based residency is proposed to be the answer to maximize training opportunity in the era of work hour restrictions and growing concerns regarding accountability in medical education. A Web-based survey was conducted to obtain feedback from Canadian general surgery residents on their experience and perception of competence within core procedures, as well as attitudes toward CBE. A total of 244 residents completed the survey. For most procedures, more than 50% of residents felt they could perform the procedure with no guidance after completing 11–30 cases. Generally, residents were welcoming of CBE; however, medium-sized programs reported some concerns regarding inadequate exposure to cases and risk of training less well-rounded surgeons. This is valuable resident feedback for programs to consider during the implementation process.

Trauma Resident Exposure in Canada and Operative Numbers (TraumaRECON): a study protocol for a national multicentre study of operative, nonoperative and structured educational exposures in Canada.

Canada's shift toward nonoperative trauma management, coupled with the implementation of competency-based medical education, has highlighted the lack of quantitative knowledge about the volume and quality of exposure to operative trauma training experiences among Canadian general surgery residents. We aim to quantify the exposure to specific operative trauma domains during residency over time and across participating Canadian training programs and to perform an environmental scan of the nonoperative clinical exposure and other formal and informal trauma education provided to general surgery residents across Canadian training programs. Trauma Resident Exposure in Canada and Operative Numbers (TraumaRECON) is a retrospective, multicentre study of operative trauma procedures involving the participation of general surgery residents in Canada. Participating sites will populate a data abstraction form outlining operative trauma data points as abstracted from eligible trauma operative charts via each site's trauma registry. They will also complete a survey of the nonoperative clinical and other educational opportunities in trauma care to which general surgery residents are exposed in participating general surgery training programs. The primary outcome of this study will be the volume of operative trauma cases that general surgery residents are exposed to during their residency in Canada. Secondary outcomes will include the association between time of occurrence during the day for trauma operations and resident participation, operative volume stratified by postgraduate year of training, volume of missed operative trauma opportunities, volume of operative trauma cases by type, and the operative role of residents involved in trauma operations. The need for competency in operative trauma management will always exist; however, with potentially limited operative trauma volume, this standard may prove difficult to achieve for the next generation of general surgery residents in Canada. Results of TraumaRECON will provide a quantitative commentary on the operative trauma volume experienced by general surgery residents in Canada to inform future teaching practices in the context of competency-based medical education.

Intersectionality of Gender and Visible Minority Status Among General Surgery Residents in Canada

Within medical specialties, surgical disciplines disproportionately and routinely demonstrate the greatest underrepresentation of women and individuals from racial/ethnic minority groups. Understanding the role that diversity plays in surgical resident training may identify strategies that foster resident resiliency, optimize surgical training, and improve patient outcomes. To examine the implication of gender and visible minority (VM [ie, nonaboriginal people who are not White individuals]) status for resiliency and training experiences of general surgery residents in Canada. In this survey study, a 129-item questionnaire was emailed from May 2018 to July 2018 to all residents enrolled in all Canadian general surgery training programs during the 2017-2018 training year. Survey responses were extracted and categorized into 5 major themes. The survey was designed by the Resident Committee and reviewed by the Governing Board of the Canadian Association of General Surgeons. French and English versions of the survey were created, distributed, and administered using Google Forms. Survey questions were formulated to characterize resident diversity and training experience. Self-perceptions of diversity, mentorship, and training experience were evaluated using a 5-point Likert scale (1 for strongly disagree, 2 for disagree, 3 for neither agree or disagree, 4 for agree, and 5 for strongly agree) and open-ended responses. The frequency of perceived unprofessional workplace encounters was evaluated using a 5-point scale (1 for daily, 2 for weekly, 3 for monthly, 4 for annually, and 5 for never). Of the 510 general surgery residents invited, a total of 210 residents (40.5%) completed the survey. Most respondents were younger than 30 years (119 [56.7%]), were women (112 [53.3%]), reported English as their first language (133 [63.3%]), did not identify as a VM (147 [70.0%]), had no dependents (184 [87.6%]), and were Canadian medical graduates (178 [84.8%]). Women residents who identified as VM compared with male residents who did not identify as a VM were less likely to agree or strongly agree that they had a collegial relationship with staff, (21 [63.6%] vs 61 [89.7%]; P = .01), to feel like they fit in with their training programs (21 [63.6%] vs 56 [82.3%]; P = .003), and to feel valued at work (15 [45.4%] vs 47 [69.1%]; P = .03). Both female residents and female residents who identified as VM described significant concerns about receiving fewer training opportunities because of their gender vs their male peers (54 [48.2%] vs 3 [3.0%]; P < .001). Ninety-one of 112 female residents (81.2%) reported feeling that their medical expertise was dismissed because of their gender at least once annually, with 37 women (33.0%) experiencing dismissal of their expertise at least once every week (P < .001). In contrast, 98% of male residents reported never experiencing dismissal of their medical expertise because of their gender. Similarly, residents with VM status vs those without VM status reported at least monthly dismissal of their expertise because of their race/ethnicity (9 of 63 [14.3%] vs 1 of 147 [0.7%]; P < .001). In this study, female sex and VM status appeared to be associated with adverse implications for the training experience of general surgery residents. These findings suggest that new strategies focused on the intersectionality of gender and race/ethnicity are needed to improve the training experience of at-risk residents.

Development of a novel conceptual framework for curriculum design in Canadian postgraduate trauma training.

BackgroundRecent changes in practice patterns and training paradigms in trauma care have resulted in a critical review of postgraduate curricula. Specifically, a shift towards non-operative management of traumatic injuries, and reduced resident work-hours, has led to a significant decrease in trainees' surgical exposure to trauma. The purpose of our study is to perform an exploratory review and needs assessment of trauma curricula for general surgery residents in Canada.MethodsOur study design includes semi-structured interviews with trauma education experts across Canada and focus groups with various stakeholder groups. We performed qualitative analysis of comments, with two independent reviewers, using inductive thematic analysis to identify themes and sub-themes.ResultsWe interviewed four trauma education experts and conducted four focus groups. We formulated two main themes: institutional context and transferability of curricular components. We further broke down institutional context into sub-themes of culture, resources, trauma system, and trauma volume. We developed a new conceptual framework to guide ongoing curricular reform for trauma care within the context of general surgery training.ConclusionsThe proposed framework, developed through qualitative analysis, can be utilized in a collaborative fashion in the curricular reform process of trauma care training in Canada.

Canadian general surgery residents' need formal curricula and objective performance assessments in gastrointestinal endoscopy training: a program director census.

Methods of developing and determining General Surgery (GS) residents' competency in gastrointestinal endoscopy in Canada are not currently standardized. This study aimed to assess the status of gastrointestinal endoscopy training in Royal College of Physicians and Surgeons of Canada (RCPSC) GS residency programs. A 35-question survey was developed using GS gastrointestinal endoscopy curricula guidelines. All 17 RCPSC GS program directors were contacted to complete the questionnaire via the web-based SurveyMonkey.ca® platform. All 17 program directors completed the survey (100% response rate). Program demographics Sixteen programs reported having dedicated endoscopy rotations with a mean duration of 2.8 months (range 0-4, SD 1.1). Upon completion of dedicated endoscopy rotations, four programs (25%) reported having formal skills assessments and three (18.8%) reported formal knowledge examinations. All programs required endoscopy procedures be logged throughout residency, but only three (21.4%) included quality indicators. Only one program required residents to obtain Fundamentals of Endoscopic Surgery certification. Program outcomes The reported estimated mean number of procedures during residents' endoscopy rotations was 82 (range 10-150, standard deviation 33.6) gastroscopies and 156 (40-350, 76.3) colonoscopies. The mean number of procedures during residents' entire residencies was 150 (20-400, 98.6) gastroscopies and 241 (50-500, 76.3) colonoscopies. The number of months of dedicated endoscopy training significantly correlated with the total estimated number of endoscopic procedures performed (ρ = 0.67, p = 0.02). Eleven program directors (73.3%) believed residents were prepared for independent endoscopy practice, while four disagreed (26.7%). Program directors' perceptions of residents' preparedness were significantly correlated with the number of endoscopic procedures performed by residents (p < 0.01) but not the robustness of the endoscopy curriculum (p = 0.72). Endoscopy training in RCPSC GS residency programs is highly variable. Program directors' perceptions of residents' competency appear to be significantly correlated with procedure numbers and few have adopted formal curricula and performance assessments.

The current state of resident trauma training: Are we losing a generation?

General surgeons provide life-saving trauma care to a large portion of Canadians. Although trauma care has evolved significantly over the last few decades and now requires fewer operations, when a life-saving operation is required the expectation of competence to perform this operation has not been reduced. A recent study from the United States found decreased resident case-log volumes of trauma operations. Such findings raise the alarm of declining exposure of residents to trauma operations and beg the question of whether graduating residents are competent to care for trauma patients. Examination of the Canadian setting reveals a dearth of published information about the actual exposure of Canadian general surgery residents to trauma care. With the forthcoming evolution of general surgery education into competency-based medical education, we sound a call to action to ensure that all graduating general surgeons are able to provide the care that both the Royal College of Physicians and Surgeons of Canada and the Canadian public demand.

A cross-sectional online evaluation of burnout risk factors among general surgical residents in Canada

Background: Burnout is hallmarked by physical and psychological exhaustion, coupled with cynicism and disengagement. Evidence suggests that affected physicians not only suffer personally, but that patient safety and clinical outcomes are also negatively affected. This study aimed to identify potentially remediable risks for burnout among residents enrolled in Canadian general surgery programs. Methods: In this cross-sectional design, a questionnaire was distributed to every general surgery resident in the 15 programs consenting to participate. Questions examined the following five domains: demographics, working patterns, attitudes toward residency, life experiences, and lifestyle/outlook. Respondents' risks of burnout were assessed using the Maslach Burnout Inventory™. Univariate analysis and then multiple logistic regression were used to assess predictors. Results: A total of 114 completed questionnaires were received (22%). Of these residents, 39 (34%) met the criteria for high burnout risk. Inadequate personal/family time, a personal history of mental health or substance abuse-related issues, and moderately to poorly approachable staff/senior residents were all significantly associated with a high burnout risk (odds ratio [OR] =4.3, 95% confidence interval [CI] =1.6, 11.2, P = 0.003; OR =6.0, 95% CI = 1.6, 21.9, P = 0.007; and OR = 4.6, 95% CI = 1.7, 12.5, P = 0.003 respectively). Predicted high burnout risk probability with none of the above factors was 10%, increasing up to 40%, 75%, and 93% with one, two, or all of these risk factors present respectively. Conclusion: One-third of general surgery residents in Canada are at high burnout risk. Residency programs may have considerable influence over factors associated with this outcome to the benefit of residents, staff, and patients. The following core competencies are addressed in this article: Practice-based learning and improvement, Professionalism, Systems-based practice.

National survey of mentorship in Canadian general surgery residency programs: Where are we and what do we need?

The benefits of mentorship on residents are well established. The current state of mentorship in General Surgery (GS) residency programs in Canada is unknown. The objectives of this study were to obtain GS residents' and program directors' (PD) perspectives on resident mentorship. An electronic survey was developed and distributed to all 601 GS residents in Canada. All 17 PDs were invited for telephone interviews. A total of 179 of the 601 residents responded. Ninety-seven percent (n=173) felt mentorship was important. Only 67% (n=116) identified a mentor and only 53% (n=62) reported a mentorship program. Most who identified a mentor (n=87/110, 79%) were satisfied with the mentorship received. Significant variations in mentorship existed between demographic subgroups and mentorship program types. Overall, residents (n=121, 74%) favoured having a required mentorship program.A total of 11 out of 17 PDs participated in the telephone interviews. The majority of PDs (n=9, 82%) were satisfied with current resident mentorship but most acknowledged that barriers exist (n=8, 73%). GS programs in Canada should ensure they are providing equal opportunities for mentorship across demographic subgroups. Programs are encouraged to examine both their program's and their residents' needs as well as local barriers to improve mentorship.

Local and national laparoscopic skill competitions: residents' opinions and impact on adoption of simulation-based training.

Dedicated practice using laparoscopic simulators improves operative performance. Yet, voluntary utilization is minimal. We hypothesized that skill competition between peers, at the local and national level, positively influences residents' use of laparoscopic simulators. A web-based survey evaluated the relationship between Canadian General Surgery residents' use of laparoscopic simulation and participation in competition. Secondary outcomes assessed attitudes regarding simulation training, factors limiting use, and associations between competition level and usage. One hundred ninety (23%) of 826 potential participants responded. Eighty-three percent rated their laparoscopic abilities as novice or intermediate. More than 70% agreed that use of simulation practice improves intra-operative performance, and should be a mandatory component of training. However, 58% employed simulator practice less than once per month, and 18% never used a simulator. Sixty-five percent engaged in simulator training for 5h or less over the preceding 6months. Seventy-three percent had participated in laparoscopic skill competition. Of those, 51% agreed that competition was a motivation for simulation practice. No association was found between those with competition experience and simulator use. However, 83% of those who had competed nationally reported >5h of simulator use in the previous 6months compared to those with no competition experience (26%), local competition (40%), and local national-qualifying competition (23%) (p<0.001). This study does not support the hypothesis that competition alone universally increases voluntary use of simulation-based training, with only the minority of individuals competing at the national level demonstrated significantly higher simulation use. However, simulation training was perceived as a valuable exercise. Lack of time and access to simulators, as opposed to lack of interest, were the most commonly reported to limited use.

Thoughts of Quitting General Surgery Residency: Factors in Canada

Attrition rates in general surgery training are higher than other surgical disciplines. We sought to determine the prevalence with which Canadian general surgery residents consider leaving their training and the contributing factors. An anonymous survey was administered to all general surgery residents in Canada. Responses from residents who considered leaving their training were assessed for importance of contributing factors. The study was conducted at the Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, a tertiary academic center. The response rate was approximately 34.0%. A minority (32.0%) reported very seriously or somewhat seriously considering leaving their training, whereas 35.2% casually considered doing so. Poor work-life balance in residency (38.9%) was the single-most important factor, whereas concern about future unemployment (16.7%) and poor future quality of life (15.7%) were next. Enjoyment of work (41.7%) was the most frequent mitigating factor. Harassment and intimidation were reported factors in 16.7%. On analysis, only intention to practice in a nonacademic setting approached significant association with thoughts of leaving (odds ratio = 1.92, CI = 0.99-3.74, p = 0.052). There was no association with sex, program, postgraduate year, relationship status, or subspecialty interest. There was a nonsignificant trend toward more thoughts of leaving with older age. Canadian general surgery residents appear less likely to seriously consider quitting than their American counterparts. Poor work-life balance in residency, fear of future unemployment, and anticipated poor future quality of life are significant contributors to thoughts of quitting. Efforts to educate prospective residents about the reality of the surgical lifestyle, and to assist residents in securing employment, may improve completion rates.

Endoscopy training in Canadian general surgery residency programs.

Currently, general surgeons provide about 50% of endoscopy services across Canada and an even greater proportion outside large urban centres. It is essential that endoscopy remain a core component of general surgery practice and a core competency of general surgery residency training. The Canadian Association of General Surgeons Residents Committee supports the position that quality endoscopy training for all Canadian general surgery residents is in the best interest of the Canadian public. However, the means by which quality endoscopy training is achieved has not been defined at a national level. Endoscopy training in Canadian general surgery residency programs requires standardization across the country and improved measurement to ensure that competency and basic credentialing requirements are met.

Career Plans and Perceptions in Readiness to Practice of Graduating General Surgery Residents in Canada

Overall, 25% of American general surgery residents identified as not feeling confident operating independently at graduation, which may contribute to 70% pursuing further training. This study was undertaken to identify intended career plans of general surgery graduates in Canada on a national level, and perceived strengths and weaknesses of training that would affect transition to early practice. Questionnaires were distributed to graduating general surgery residents at a Canadian national review course in 2012 and 2013. Data were analyzed for overall trends. Overall, 75% (78/104) of graduating residents responded in 2012 and 53% (50/95) in 2013. Greater than 60% of respondents were entering a fellowship program upon graduation (49/78 in 2012 and 37/50 in 2013); the most common fellowship choices were minimally invasive surgery (24% in 2012 and 39% in 2013) or surgical oncology (16% in 2012). Most residents reported that they were completing subspecialty training to meet career goals (64/85 overall) rather than feeling unprepared for practice (0/85 overall). Most residents planned on practicing in urban centers (54%) and academic hospitals (73%). Residents perceived a need for assistance for laparoscopic adrenalectomy, neck dissection, laparoscopic splenectomy, laparoscopic low anterior resection, groin dissection, and thyroidectomy. An overwhelming majority of general surgery graduates plan to pursue fellowship training to meet career goals of working in urban, academic centers, rather than a perceived lack of competence. It is vital to describe operative competency expectations for residents and to promote a variety of practice opportunities following graduation.

The Canadian general surgery resident: defining current challenges for surgical leadership

Surgery training programs in Canada and the United States have recognized the need to modify current models of training and education. The shifting demographic of surgery trainees, lifestyle issues and an increased trend toward subspecialization are the major influences. To guide these important educational initiatives, a contemporary profile of Canadian general surgery residents and their impressions of training in Canada is required. We developed and distributed a questionnaire to residents in each Canadian general surgery training program, and residents responded during dedicated teaching time. In all, 186 surveys were returned for analysis (62% response rate). The average age of Canadian general surgery residents is 30 years, 38% are women, 41% are married, 18% have dependants younger than 18 years and 41% plan to add to or start a family during residency. Most (87%) residents plan to pursue postgraduate education. On completion of training, 74% of residents plan to stay in Canada and 49% want to practice in an academic setting. Almost half (42%) of residents identify a poor balance between work and personal life during residency. Forty-seven percent of respondents have appropriate access to mentorship, whereas 37% describe suitable access to career guidance and 40% identify the availability of appropriate social supports. Just over half (54%) believe the stress level during residency is manageable. This survey provides a profile of contemporary Canadian general surgery residents. Important challenges within the residency system are identified. Program directors and chairs of surgery are encouraged to recognize these challenges and intervene where appropriate.

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The purpose of this study was to describe Canadian general surgery residents' perceptions regarding potential implementation of work-hour restrictions. An ethics review board-approved, Web-based survey was submitted to all Canadian general surgery residency programs between April and July 2009. Questions evaluated the perceived effects of an 80-hour work week on length of training, operative exposure, learning and lifestyle. We used the Fisher exact test to compare senior and junior residents' responses. Of 360 residents, 158 responded (70 seniors and 88 juniors). Among them, 79% reported working 75-100 hours per week. About 74% of seniors believed that limiting their work hours would decrease their operative exposure; 43% of juniors agreed (p < 0.001). Both seniors and juniors thought limiting their work hours would improve their lifestyle (86% v. 96%, p = 0.12). Overall, 60% of residents did not believe limiting work hours would extend the length of their training. Regarding 24-hour call, 60% of juniors thought it was hazardous to their health; 30% of seniors agreed (p = 0.001). Both senior and junior residents thought abolishing 24-hour call would decrease their operative exposure (84% v. 70%, p = 0.21). Overall, 31% of residents supported abolishing 24-hour call. About 47% of residents (41% seniors, 51%juniors, p = 0.26) agreed with the adoption of the 80-hour work week. There is a training-level based dichotomy of opinion among general surgery residents in Canada regarding the perceived effects of work hour restrictions. Both groups have voted against abolishing 24-hour call, and neither group strongly supports the implementation of the 80-hour work week.

Canadian Association of General Surgeons statement on endoscopy

The provision of diagnostic and therapeutic endoscopy and colonoscopy is essential to the health and well-being of the Canadian public. In continuing to address this health care need, the Canadian Association of General Surgeons (CAGS) supports and promotes access to endoscopic resources for general surgeons as well as the training of general surgery residents in endoscopy and colonoscopy. For the health care of Canadians, it is critical that endoscopic resources are securely accessible throughout training and into practice. Preliminary investigation into endoscopic services provided by general surgeons in Canada was recently undertaken by the provincial and territorial representatives on the CAGS Provincial Affairs Committee. Owing to the variety of data-gathering methods in each province, the purest common measurable data available were colonoscopy billing data by specialty. All provincial representatives requested colonoscopy billing totals from their respective provincial medical services branches (Table 1). Table 1 Colonoscopy procedures by province and specialist, 2010 Currently in Canada, general surgeons perform 50% or more of all colonoscopies. The remainder is provided by gastroenterologists or “other” health care providers (Table 1). In addition, general surgeons perform most endoscopic procedures in provinces that do not have large urban centres. This confirms that general surgeons are the primary providers of endoscopy services in rural areas. The number of Canadians requiring endoscopies and colonoscopies is increasing with the advancing age of our population. In addition, owing to the nature of the patient health issues that general surgeons diagnose and treat, CAGS maintains that general surgeons are an essential component of any health care strategy — local, provincial or national — to provide safe and timely endoscopic services. A practising general surgeon requires a minimum of one-half to one full day of endoscopy time per week. The variation takes into account those general surgeons whose practices may have an increased focus on the gastrointestinal tract, such as colorectal surgeons and hepatobiliary pancreatic surgeons requiring endoscopic retrograde cholangiopancreatography resources. It is the opinion of CAGS that quality endoscopy training for all Canadian general surgery residents is in the best interest of the Canadian public. The Royal College of Physicians and Surgeons of Canada objectives of training for general surgery include endoscopy and colonoscopy; general surgery training programs and their faculties must have access to endoscopy resources in all hospitals where residents train. General surgeons in Canada have been and remain committed to providing safe and quality endoscopy services. Members of CAGS are encouraged to participate in quality-assurance programs and continuing medical education to provide the best possible care for patients. The ongoing endoscopy training of surgical residents is absolutely essential, as is the continued involvement of general surgeons in the provision of endoscopic services. We at CAGS firmly believe that any attempts to exclude surgical residents from training in endoscopy or any attempts to hamper a trained surgeon’s provision of endoscopic services can only lead to inadequate care for the Canadian public.