Time-based Training Research Articles

48 Evaluation without representation: Paediatric residents perspectives on CBME

Abstract Background Paediatrics transitioned in 2021 to Competence By Design (CBD), a postgraduate education model spearheaded by the Royal College of Physicians and Surgeons of Canada (Royal College). CBD replaced a time-based training system with one based on competencies demonstrated through regular observations of trainee performance. Although intended to be learner-centered, resident voices have been underrepresented in CBD’s design. Objectives We sought to (1) understand how paediatric residents perceived CBD as impacting their education and evaluation, and (2) explore their ideas to improve its implementation. Design/Methods We compared three Canadian postgraduate paediatric residency programs. First, we reviewed Royal College and program-specific documents regarding CBD to understand local and national priorities for its implementation. Program directors and local education leads were then interviewed to understand local priorities and implementation practices at these programs. Lastly, we conducted interviews with paediatric residents that began residency the year that CBD was launched. We used reflexive, inductive analysis to analyze their perspectives on how CBD has affected their education and develop learner-informed recommendations for improvement. Results We interviewed six program directors and CBD leads. Identified programmatic benefits included improved trainee surveillance, facilitated curriculum change, and competency committees. Challenges included untrained faculty, workplace-based assessment tensions, and administrative burden on residents and staff. Subsequent interviews with ten paediatric residents demonstrated CBD as having limited benefit to their education, leading to a checklist mentality of EPA completion and disengagement with the CBD system. These perceptions were influenced by (1) administrative burden, (2) poor quality feedback from disengaged staff with limited coaching experience, and (3) a lack of collaborative communication between the residents, their programs, and the Royal College. Residents suggested improvements, including: decreasing the number of assessments to alleviate time burden on both residents and faculty; implementing formal coaching instruction for residents and staff; and improving dialogue between Royal College, competency committees, and residents and physician evaluators to build buy-in with the system and facilitate continuing process improvement. Conclusion If we are to effectively adapt postgraduate educational systems to equip learners with the skills to meet the needs of the societies they serve, centering resident voices in curricular revision is paramount to maximize learner buy-in, minimize unintended administrative burden, and guide the development of necessary institutional supports (e.g., formal coaching) to ensure successful system transformation.

Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education.

Competency-based medical education is increasingly regarded as a preferred framework for physician training, but implementation is limited. U.S. residency programs remain largely time based, with variable assessments and limited opportunities for individualization. Gaps in graduates' readiness for unsupervised care have been noted across specialties. Logistical barriers and regulatory requirements constrain movement toward competency-based, time-variable (CBTV) graduate medical education (GME), despite its theoretical benefits. The authors describe a vision for CBTV-GME and an implementation model that can be applied across specialties. Termed "Promotion in Place" (PIP), the model relies on enhanced assessment, clear criteria for advancement, and flexibility to adjust individuals' responsibilities and time in training based on demonstrated competence. PIP allows a resident's graduation to be advanced or delayed accordingly. Residents deemed competent for early graduation can transition to attending physician status within their training institution and benefit from a period of "sheltered independence" until the standard graduation date. Residents who need extended time to achieve competency have graduation delayed to incorporate additional targeted education. A proposal to pilot the PIP model of CBTV-GME received funding through the American Medical Association's "Reimagining Residency" initiative in 2019. Ten of 46 residency programs in a multihospital system expressed interest and pursued initial planning. Seven programs withdrew for reasons including program director transitions, uncertainty about resident reactions, and the COVID-19 pandemic. Three programs petitioned their specialty boards for exemptions from time-based training. One program was granted the needed exemption and launched a PIP pilot, now in year 4, demonstrating the feasibility of implementing this model. Implementation tools and templates are described. Larger-scale implementation with longer-term assessment is needed to evaluate the impact and generalizability of this CBTV-GME model.

Competency-Based Time-Variable Anesthesiology Residency Training: Identification of Problems and Solutions.

Global medical education is gradually moving toward more comprehensive implementations of a competency-based education (CBE) model. Elimination of standard time-based training and adoption of time-variable training (competency-based time-variable training [CB-TVT]) is one of the final stages of implementation of CBE. While CB-TVT has been implemented in some programs outside the United States, residency programs in the United States are still exploring this approach to training. The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) are encouraging member boards and residency review committees to consider innovative ways programs could implement CB-TVT. The goals of this study were to (1) identify potential problems with the implementation of CB-TVT in anesthesiology residency training, (2) rank the importance of the problems and the perceived difficulty of solving them, and (3) develop proposed solutions to the identified problems. Study participants were recruited from key stakeholder groups in anesthesiology education, including current or former program directors, department chairs, residents, fellows, American Board of Anesthesiology (ABA) board members, ACGME residency review committee members or ACGME leaders, designated institutional officials, residency program coordinators, clinical operations directors, and leaders of large anesthesiology community practice groups. This study was conducted in 2 phases. In phase 1, survey questionnaires were iteratively distributed to participants to identify problems with the implementation of CB-TVT. Participants were also asked to rank the perceived importance and difficulty of each problem and to identify relevant stakeholder groups that would be responsible for solving each problem. In phase 2, surveys focused on identifying potential solutions for problems identified in phase 1. A total of 36 stakeholders identified 39 potential problems, grouped into 7 major categories, with the implementation of CB-TVT in anesthesiology residency training. Of the 39 problems, 19 (48.7%) were marked as important or very important on a 5-point scale and 12 of 19 (63.2%) of the important problems were marked as difficult or very difficult to solve on a 5-point scale. Stakeholders proposed 165 total solutions to the identified problems. CB-TVT is a promising educational model for anesthesiology residency, which potentially results in learner flexibility, individualization of curricula, and utilization of competencies to determine learner advancement. Because of the potential problems with the implementation of CB-TVT, it is important for future pilot implementations of CB-TVT to document realized problems, efficacy of solutions, and effects on educational outcomes to justify the burden of implementing CB-TVT.

Is it time for integrated academic pathways in SET training?

Patients benefit from receiving care in hospitals with a strong engagement in clinical research. Some of these benefits result from institutional factors such as hospital volume and resources, but the academic competencies of surgical teams play a significant role in high quality patient care.1, 2 Surgeons with doctorate degrees are more likely to publish and obtain research grants throughout their career, and units they work in report higher rates of trainee research success and satisfaction, improved patient outcomes and greater clinical guideline adherence.3 When research is fully integrated into organizational structures, health-care performance is superior to less formal research.3 Whilst not all trainees aspire for long-term academic career trajectories, it is important for surgical training programs to address the sustainability of academic pathways. Prevalent models of surgical training do not readily support simultaneous acquisition of clinical competencies alongside more focused academic training and higher research degrees. In Australia and Aotearoa New Zealand, most surgical education and training (SET) programs allow trainees to suspend training for up to 1–2 years to complete higher research degrees. Some trainees can arrange less-than-full-time (LTFT) training positions that allow them extra time for research, but these LTFT positions can be difficult to arrange, and often are not geographically located near the trainee's research centre. Engaging in part-time research is also hindered by financial concerns, as most RACS research scholarships are only available for trainees undertaking full-time research. When re-entering clinical training after prolonged research-related absence, trainees can encounter significant challenges. The stress of returning to work, combined with loss of confidence and skills, significantly impacts trainee wellbeing and performance.4 In Nash's study of paediatric surgical trainees returning to clinical work after an interval away from training, clinical confidence needed time to be re-established: ‘I don't think your hands forget how to operate, I think it's your brain that does not have the confidence to do it’.4 Clinical and technical skills may need to be redeveloped, and time-based training programs have little flexibility to allow for this. Reestablishment of professional identity and connections with peers was also important, with many returning trainees feeling doubts about their career.4, 5 Trainees returning to academia after completing a full-time training period, typically have a considerable reduction in their research output and publications. Reduced academic output during these clinical training years hinder future competitiveness for larger research grant funding, and limit their eligibility for grants targeted towards early career researchers. Experiences from international training programs provide insights into how we can address this challenge. The integrated Clinical Academic Fellowship pathways for surgical training in the United Kingdom (UK) are well established and have been demonstrated to improve both research output and clinical skill development.6, 7 Research pathways integrated into residency training in the United States resulted in participants scoring higher on national board examinations, improved research productivity and sustained academic success.8, 9 UK ENT trainees who undertook LTFT in dedicated integrated research programs achieved more publications and academic output than non-integrated trainees in both full-time and part-time clinical positions.10 Trainees benefit from the cognitive synergy of combining clinical training and academic research relevant to their areas of expertise.11, 12 Integration of research within clinical practice, rather than prolonged intervals of full-time research, is a mechanism to provide support, link clinical skill acquisition to academic competency development, and recognize progression through training pathways.13 Trainees who participate in integrated research programs report positive work-life balance, ability to develop longitudinal research interests and sustained engagement in academic surgery.6 Despite inbuilt pathways in other surgical training systems, academic trainees continue to face challenges, including accessing protected time away from clinical duties, negative attitudes from others in the workplace, and difficulties accessing academic supervision.6 In vascular surgery, we are undertaking research to explore and codesign alternative models of training, including integrated pathways for academic development in clinical training. It is important to obtain input from trainees, supervisors and healthcare employers as to how these models can be implemented in our local context in Australia and Aotearoa. We anticipate logistical, educational and cultural challenges as these pathways are developed. Ensuring trainees are able to complete higher degrees will require strong partnerships with universities, with a clear vision for a sustainable academic surgical workforce. As we move forward in this process, we aspire for training to be flexible and adaptive to the needs of our trainees, hospitals and communities. Carina Cutmore: Conceptualization; data curation; writing – original draft; writing – review and editing. Hamid Hajian: Conceptualization; data curation; writing – review and editing. Sarah Aitken: Conceptualization; data curation; resources; supervision; writing – original draft; writing – review and editing.

The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study.

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

Competency-Based Medical Training in Anesthesiology: Has It Delivered on the Promise of Better Education?

Competency-Based Medical Training in Anesthesiology: Has It Delivered on the Promise of Better Education?

Psychiatry training for medical students: A global perspective and implications for India's competency-based medical education curriculum.

Competency-based medical education curriculum (CBME) has received traction worldwide. However, its adoption and implementation have significantly varied across the globe. The National Medical Commission, India (2019) has adopted CBME to improve the quality and content of training of medical students. However, the ongoing COVID-19 pandemic has spawned several challenges implementing the CBME. Therefore, there is a need to reflect on using novel teaching and assessment methods to enrich medical and psychiatric training. In this paper, we aimed to study global trends and characteristics of competency-based psychiatry training programs and how these experiences can be utilized to overcome challenges and facilitate the implementation of CBME in Psychiatry in the Indian context. A literature search was conducted using PubMed and Google Scholar databases. The findings are presented narratively. Psychiatry training for medical students greatly vary across the globe. High-income countries mainly have implemented CBME and have incorporated psychiatry training during the foundation/pre-clerkship period itself. There is more reliance on skill development and flexible and learning-based training vs. time-based training. Various enrichment activities have been incorporated into the medical curriculum to promote and strengthen psychiatry training for medical students, particularly in developed nations, which have yielded positive results. Although the COVID-19 pandemic has adversely affected the medical student’s training, it has reiterated the significance of skill-based education and opened novel avenues for implementing the CBME.Medical educationists need to adapt themselves to provide CBME to the students. Making structural, curricular changes, orienting teachers, and students about the CBME, mentoring teachers, adopting novel training and assessment methods, utilizing enrichment activities, collaborating with educational institutions and technology providers, periodically evaluating the implementation of the CBME, and making appropriate course corrections are essential. In addition, there is a need to address structural barriers, such as lack of workforce, for better realization of the CBME objectives.eriodically evaluating the implementation of the CBME, and making appropriate course corrections are essential. Additionally, there is a need to address structural barriers, such as lack of workforce, for better realization of the CBME objectives.

Evolution of Post Graduate Curricula in Pakistan

Evolution of Post Graduate Curricula in Pakistan

How to train thoracic anesthesia for residents and consultants?

The training of anesthesiologists in thoracic surgery is a significant challenge. International professional societies usually provide only a case number-based or time-based training concept. There are only a few concepts of simulation trainings in thoracic anesthesia and interprofessional debriefings on a daily basis are rarely applied. In this review, we will show how professional curricula should aim for competence rather than number of cases and why simulation-based training and debriefing should be implemented. Recent curricula recommend so-called entrustable professional activities (EPAs)as a way out of the dilemma between the number of cases vs. competence. With these EPAs, competence can be mapped and prerequisites defined.Training concepts from simulation in healthcare have so far not explicitly reached anesthesia for thoracic surgery. In addition to mere technical training, combined technical-behavioral training forms have proven to be an effective training targeting the entire team in the context of the actual working environment in the operating theatre. Interdisciplinary and interprofessional learning can take place in simulation trainings and on a daily basis through postevent debriefings. When these debriefings are conducted in a structured way, an improvement in the performance of the entire team can be the result. The basis for these debriefings - as well as for other training approaches - is psychological safety, which should be established and maintained together with all professions involved.

Training in neonatal neurocritical care: a proposal for a hybrid model of competence by design and time-based methods.

Neonatal neurocritical care (NNCC) is a rapidly advancing field with limited fellowship training available in locally developed, non-accredited programs. A standardized survey aimed to understand the training backgrounds of individuals practicing NNCC, the structure of existing clinical NNCC services/training programs, and suggested clinical competencies for new graduates. We developed an anonymous survey electronically sent to members of societies related to NNCC. Using the survey results as a guide, we discuss acompetence by design (CBD) curriculum as a complementary approach to traditional time-based training. There were 82 responses to the survey from 30 countries; 95% of respondents were physicians. Thirty-one (42%) institutions reported having an NNCC service, 24 (29%) individuals reported formal NNCC training, 81% reported "significant variability" across NNCC training programs, and 88% were both in favor of standardizing training programs and pursuing formal accreditation for NNCC in the next 5 years. The survey results demonstrate international interest in standardizing NNCC training and development of an accreditation or certification process. We propose consideration of a CBD-type curriculum as a training approach to focus on the development of specific NNCC competencies, rather than assuming the acquisition of these competencies based on time as a surrogate. Continued growth and development in the field of NNCC has led to increasing need for training programs suited to meet the diverse needs of trainees from varied backgrounds. We present the results of an international survey that assessed the structure of existing training programs and the priority areas in which graduates must demonstrate competence, highlighting the combination of CBD and time-based training as one approach to address these recommendations. The survey results support interest in translating published training competencies, existing expertise, and infrastructure across centers into a standardized curriculum for NNCC including certification opportunities.

Toward Competency-Based Training: To What Extent Are We Competency-Based?

Time-based training models in plastic surgery vary in exposure, resulting in low confidence levels among graduates. The evolution of postgraduate medical education into a competency-based model to address these issues requires an understanding of interventions described in the plastic surgery literature to identify gaps and guide creation of assessments to demonstrate competence. A systematic search of the MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Cochrane databases from inception until December of 2017 was conducted using search terms and synonyms of educational interventions reported in plastic surgery. Full texts were retrieved following filtering and data extracted were related to intervention design and execution, involvement of competency assessment, and educational objectives and alignment to Accreditation Council for Graduate Medical Education competencies and Royal College of Physicians and Surgeons of Canada Canadian Medical Education Directives for Specialists roles. Study quality was assessed using Kirkpatrick's levels of learning evaluation, validity evidence, and the Medical Education Research Study Quality Instrument score. Of the initial 4307 results, only 36 interventions met the inclusion criteria. Almost all interventions aligned to medical knowledge and patient care Accreditation Council for Graduate Medical Education competencies. One-fifth of the interventions involved no assessment of competency, whereas most displayed assessment at the level of design as opposed to outcomes. Quality assessment revealed low levels of learning evaluation and evidence of validity; the average Medical Education Research Study Quality Instrument score was 10.9 of 18. A systematic review of educational literature in plastic surgery was conducted to assess the quality of reported educational interventions, and to help guide creating tools that ensure competency acquirement among trainees.

Commentary on: Resident Exposure to Aesthetic Surgical and Nonsurgical Procedures During Canadian Residency Program Training.

Competency-based postgraduate medical education is well defined as “an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centeredness.” 1 Starting in 2020, the newest cohort of Canadian plastic surgery residents must now complete a curriculum based on satisfactorily completing 40 Core Entrustable Professional Activities (EPAs) to graduate. These EPAs are similar to the Plastic Surgery Milestones of the US Accreditation Council for Graduate Medical Education, and both are the product of collaborative efforts from a number of experts in the field. Because aesthetic surgery is considered an essential component of plastic surgery training throughout the world, 5 of Canada’s new Core EPAs are aesthetic in nature. The assessment and technical ability to independently perform breast, body, and facial aesthetic surgery has...

Preclinical Proficiency-Based Model of Ultrasound Training.

Graduate medical education is being transformed from a time-based training model to a competency-based training model. While the application of ultrasound in the perioperative arena has become an expected skill set for anesthesiologists, clinical exposure during training is intermittent and nongraduated without a structured program. We developed a formal structured perioperative ultrasound program to efficiently train first-year clinical anesthesia (CA-1) residents and evaluated its effectiveness quantitatively in the form of a proficiency index. In this prospective study, a multimodal perioperative ultrasound training program spread over 3 months was designed by experts at an accredited anesthesiology residency program to train the CA-1 residents. The training model was based on self-learning through web-based modules and instructor-based learning by performing perioperative ultrasound techniques on simulators and live models. The effectiveness of the program was evaluated by comparing the CA-1 residents who completed the training to graduating third-year clinical anesthesia (CA-3) residents who underwent the traditional ultrasound training in the residency program using a designed index called a "proficiency index." The proficiency index was composed of scores on a cognitive knowledge test (20%) and scores on an objective structured clinical examination (OSCE) to evaluate the workflow understanding (40%) and psychomotor skills (40%). Sixteen CA-1 residents successfully completed the perioperative ultrasound training program and the subsequent evaluation with the proficiency index. The total duration of training was 60 hours of self-based learning and instructor-based learning. There was a significant improvement observed in the cognitive knowledge test scores for the CA-1 residents after the training program (pretest: 71% [0.141 ± 0.019]; posttest: 83% [0.165 ± 0.041]; P < .001). At the end of the program, the CA-1 residents achieved an average proficiency index that was not significantly different from the average proficiency index of graduating CA-3 residents who underwent traditional ultrasound training (CA-1: 0.803 ± 0.049; CA-3: 0.823 ± 0.063, P = .307). Our results suggest that the implementation of a formal, structured curriculum allows CA-1 residents to achieve a level of proficiency in perioperative ultrasound applications before clinical exposure.

De-emphasizing time-based training in the delivery of competency-based medical education for undergraduates in India

In the conventional medical curriculum in India, the duration of medical graduation is 4.5 years, excluding internship. The limitation of time-based advancement can be understood in two ways, either a student is sent to next professional year without attainment of the desired course outcomes or that students spend unnecessary time in a specific professional even after gaining the required outcomes. Acknowledging these limitations and also after realizing the multiple benefits attributed to Competency Based Medical Education (CBME), the same has been implemented in the Indian set-up for undergraduate courses from 2019 batch onwards. In general, CBME advocates against time-based training, especially because not every student can learn at an identical pace. However, adoption of the same strategy (time-variable) in imparting medical education has its own challenges. In India, even though, in principle, we have adopted all principles of CBME, except the time-variability of the course. However, now the same question arises, if all students learn at varying pace, how can we ensure that within a specified time duration, all the students will attain the desired outcomes? Even though, the task at hand is difficult, it can be accomplished, if we all work together in a planned and coordinated manner. In the mission to produce a competent medical graduate within a defined time interval, there is an immense need for better planning, support from administration, active participation of faculty members, involvement of the students, and better collaboration between departments.

Exploring faculty perspectives on competency-based medical education: A report from India.

INTRODUCTION:Medical education in India is experiencing a paradigm shift from traditional curriculum to competency-based medical education (CBME). It de-emphasizes time-based training and promises greater accountability, flexibility, and learner centeredness. Faculty development is integral in the context of CBME. Considering faculty perceptions toward the new CBME and addressing the difficulties will play a vital role in successful implementation.MATERIALS AND METHODS:A cross-sectional study was carried out among 297 teaching faculty in 91 medical colleges across 20 states all over India between February and July 2020. A structured validated questionnaire on CBME was used to collect the responses through Google forms and was exported and analyzed in Microsoft Excel.RESULTS:More than 80% opined that Faculty members in departments are not adequate for successful CBME implementation. Reflective learning, early clinical exposure, and elective posting were accepted by 60.2%, 70.4%, and 45.5% of the faculty, respectively. Around 81.8% welcomed horizontal integration, whereas only 54.2% favored vertical integration during the Phase I MBBS.CONCLUSION:Few reforms such as curtailing the duration of foundation course, sensitization of all medical teachers through faculty development programs, better synchronized vertical integration, increasing the strength of faculty in each department, and adequate infrastructure for skills laboratory can be undertaken as per faculty suggestions.

What Can a Pandemic Teach Us About Competency-based Medical Education?

Medical education is moving towards competency-based medical education (CBME) where learning and assessment are focused on predefined abilities and outcomes. While medical student and residency training have defined competencies and objectives that trainees need to achieve, training remains time -based. Students and residents graduate based on a preset length of training. The COVID -19 pandemic is disrupting educational and clinical environments and in some regions the workforce may not be adequate to respond to the needs of the community. This, therefore, presents an opportunity for the medical education community to reconsider time-based training and embrace a competency-based progression to accelerate entry into the workforce. This commentary discusses undergraduate and graduate medical education response to workforce pressures of COVID-19. On one hand, some medical schools are moving towards competency-based (early) graduation from medical school. On the other hand, residency programs have generally held to time -based completion of training. In the context of this clinical and educational disruption, there are two challenges to CBME progression of trainees. The first challenge is whether there is trust in competency-based assessment to permit time independent progression. The second involves a number of logistical issues to competency-based progression.

Resources for Educating, Training, and Mentoring All Physicians Providing Palliative Care.

This article presents a rapid review of the published literature and available resources for educating Canadian physicians to provide palliative and end-of-life care. Several key messages emerge from the review. First, there are many palliative care educational resources already available for Canadian physicians. Second, the many palliative care education resources are often not used in physician training. Third, we know that some palliative care educational interventions are inexpensive and scalable, while others are costly and time-consuming; we know very little about which palliative care educational interventions impact physician behavior and patient care. Fourth, two palliative care competency areas in particular can be readily taught: symptom management and communication skill (e.g., breaking bad news and advance care planning). Fifth, palliative care educational interventions are undermined by the "hidden curriculum" in medical education; interventions must be accompanied by continuing education and faculty development to create lasting change in physician behavior. Sixth, undergraduate and postgraduate medical training is shifting from a time-based training paradigm to competency-based training and evaluation. Seventh, virtually every physician in Canada should be able to provide basic palliative care; physicians in specialized areas of practice should receive palliative care education that is tailored to their area, rather than generic educational interventions. For each key message, one or more implications are provided, which can serve as recommendations for a framework to improve palliative care as a whole in Canada.

Future generation of anesthesiologists: What professional qualifications should we aim for?

In recent years, time-based training has been replaced by competency-based training in many medical specialities in Europe. Anesthesiology has been at the forefront of these developments. The main advantage of a competency-based training lies in the shift from knowledge acquisition to knowledge application. Competence-based training doesn't replace knowledge-based training, but complements the latter, especially in the more advanced setting.The role of the anesthesiologist has extended from the operating room as the main area of competence to new responsibilities outside the operating room. The previously described four most important roles for anesthesiologists, published by the EBA (European Board of Anesthesiology) in 2008, are still useful to summarize the broader range of responsibilites: medical expert, leader/manager, scholar and professional. The role as leader in the perioperative field and manager of the operating room is gaining in importance, especially in today's environment of cost containment. Management is the field where our specialty can have the biggest impact on patient processes and efficiency of the perioperative setting.In addition to the above mentioned four main roles, anaesthesiologist should be highly self-motivated and have the ability to withstand long working hours and night shifts. A considerable number of consensual factors (time constraints, excessive and fluctuating workload, complexity of task, lack of job control) can cause stress, resulting in a high burn-out rate among anesthesiologist. Personal factors such as a high level of emotional intelligence and realistic self-awareness are important prerequisites for this profession and have to be fostered throughout the professional development and career.

Construct and face validity of the educational computer-based environment (ECE) assessment scenarios for basic endoneurosurgery skills.

In neurosurgery education, there is a paradigm shift from time-based training to criterion-based model for which competency and assessment becomes very critical. Even virtual reality simulators provide alternatives to improve education and assessment in neurosurgery programs and allow for several objective assessment measures, there are not many tools for assessing the overall performance of trainees. This study aims to develop and validate a tool for assessing the overall performance of participants in a simulation-based endoneurosurgery training environment. A training program was developed in two levels: endoscopy practice and beginning surgical practice based on four scenarios. Then, three experiments were conducted with three corresponding groups of participants (Experiment 1, 45 (32 beginners, 13 experienced), Experiment 2, 53 (40 beginners, 13 experienced), and Experiment 3, 26 (14 novices, 12 intermediate) participants). The results analyzed to understand the common factors among the performance measurements of these experiments. Then, a factor capable of assessing the overall skill levels of surgical residents was extracted. Afterwards, the proposed measure was tested to estimate the experience levels of the participants. Finally, the level of realism of these educational scenarios was assessed. The factor formed by time, distance, and accuracy on simulated tasks provided an overall performance indicator. The prediction correctness was very high for the beginners than the one for experienced surgeons in Experiments 1 and 2. When non-dominant hand is used in a surgical procedure-based scenario, skill levels of surgeons can be better predicted. The results indicate that the scenarios in Experiments 1 and 2 can be used as an assessment tool for the beginners, and scenario-2 in Experiment 3 can be used as an assessment tool for intermediate and novice levels. It can be concluded that forming the balance between perceived action capacities and skills is critical for better designing and developing skill assessment surgical simulation tools.

Competence, competency-based education, and undergraduate dental education: a discussion paper.

The aim of undergraduate dental education is to provide competent dentists to serve societal needs and improve population oral healthcare. Competency-based education has influenced the development of dental education for decades but this term is problematic. This article explores components of competency-based undergraduate health professional education in order to help the dental profession have a better understanding of the context and purposes of undergraduate dental education. This is a discussion paper based on a wide reading of the literature on the education of health professionals with a specific focus on competency-based undergraduate education. Competence comprises an integration of knowledge, skills and attitudes indicating a capability to perform professional tasks safely and ethically. The process of becoming a competent practitioner is complex. Four characteristics of competency-based education are: curriculum components and content shaped by societal needs; focused on student-centred learning; learning achievement; and limited attention to time-based training and numerical targets. Alongside a competency-based approach, undergraduate dental education can be influenced by institutional features and external factors but these receive little consideration in the literature. Understanding competence, competency-based education, and institutional and external factors will help to improve educational quality, define roles and professional development for the dental educator, and inform further research.