Incorporating CanMEDS in Residency Training Final 1

Incorporating CanMEDS In Residency Training:

Actions & Future Plans at the Department of Medicine at KAMC,

Riyadh, KSA

Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBSChairman, CanMEDS Syllabus Subcommittee

Department of Medicine, KAMC,KSA

Objectives Why do we need to include CanMEDS in

Residents Education Curricula Prerequisites for a successful program What have the Department of Medicine

done? Future Directions

Is there a clear need for change: Characteristics of current Heath care?T/F1. High Efficiency & Productivity

2. Contained Healthcare Costs

3. Guaranteed Good Clinical Outcomes

4. High Patient Care Quality (No Medical Errors)

5. No Unnecessary & Duplicate Tests

6. High Patient Satisfaction

7. High Patient Engagement

8. Comprehensive Dual Preventive as well as Therapy Inputs

Process Diagram

Process

Input

Output

Process

Input

Output

Process

Input

OutputX

Health Care Model: Donabedian Model

Process

Structure

OutcomePrevent the

Six Ds:DeathDiseaseDisabilityDiscomfortDissatisfactionDestitution (cost)

Care Process

Anatomy

• Pathways• Protocols• Physician

orders• Nursing Care• Housekeepin

g• Transport

• Staff• Department

s• Equipment• Supplies• Environme

nt

Hypotheses, health issues (problems and diagnoses), risks

TreatmentMedication and prescriptions

Symptoms and history

Body physical examination findings

Procedures and operations

Conventional medical summary

Care planning

Advice and education

Chronic disease management

Tests and investigations

Self management and home monitoring

Protocols, guidelines, care pathways

Prevention and screening, population health measures

Communication, team-based collaboration

Well-being and fitness, rehabilitation after illness

Consent, permissions, disclosures, complaints

Social welfare, culture, religion, attitudes, expectations, hopes, fears

The Patient Journey: Chances of Poor Performance?

Care Process

Needs a Sino-atrial Node to keep it ticking!

Care Process

Needs a COMPETENT workforce to keep it ticking!

Care Process

Multiple Competencies

How is the world making better doctors?

‘Scottish Doctor’

‘Tomorrow’s Doctor’

CanMEDS 2000

World Federation for Medical Education

‘Good Medical Practice’

Accreditation Council for Graduate Medical Education

WHO/EMRO

Gulf Cooperation Council

Association of American Medical Colleges

Institute for International Medical Education

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Why Outcome-based, Competency-focused Training?

OUTCOME-BASEDMEDICAL TRAINING:

HAVING THE END PRODUCTIN MIND

Building your Curriculum………..

What is Competency? Is a standardized requirement for an

individual to properly perform a specific job. It encompasses a combination of knowledge,

skills and attitude (behavior) utilized to improve performance.

More generally, competency is the state or quality of being adequately or well qualified, having the ability to perform a specific role.

Holistic Quality

• Quality Clinical Care

Clinical Skills

• Holistic Continuous Quality Care

Non-Clinical Skills

Importance of a Holistic Professional development not only Clinical Skills Training

17

What Does CanMEDS stand for?

CanMEDS 2005 Framework

“Canadian Medical Education

Directions for Specialists”…

Better standards. Better physicians. Better care.

18

CanMEDS Project Goal

To identify the core competencies generic to all specialists to meet the needs of society.

What are CanMeds competencies?

The SEVEN

Habits of a Highly Effective

Doctor

CANMEDS

1• Be proactive (take control of your destiny) • Principles of Personal Vision.

2• Begin with the End in mind • Principles of Personal Leadership

3• Put first things first • Principles of Personal Management.

4• Think win-win • Principles of Interpersonal Leadership

5

• Seek first to understand. . . Then to be understood • Principles of Empathic Communication with patients, colleagues

etc

6• Synergize • Principles of creative cooperation

7• Sharpen the saw (Continuous Improvement) • Principles of Balanced Self-Renewal

Collaborator/Advocate

Communicator

Scholar

Manager

Manager

Medical Expert

Manager/Professional

Medical Expert

Optimal clinical, procedural, ethical

and patient-centered medical care

Establish and maintain clinical

knowledge appropriate to their

practice

Communicator

Documentation

Consultation skills

Counseling skills/ Breaking bad news

(verbal and non-verbal )

Collaborator

Clinical Care Collaboration

Community

International

Scholar

Continuous professional Development

Evidence-Based Practice

Teaching

Research

Advocate

Patient Healthcare Needs

Community Health Needs

Population Determinants of

Health

Professional

Ethical Practice

Professional Practice

Self-Care

Manager

Health Care

Effective Healthcare

Career Development

Administrative Development

The Department of Medicine CanMEDS Syllabus

1• Definition of each Competency

2• Sub-competency

3• Recommended Activity

4• Recommended Method of Delivery

5• Recommended Assessment Tools

Sub-competency Recommended Activity Recommended Method of Delivery

Recommended Assessment Tool

Optimal clinical, procedural, ethical and patient-centered medical care

1. CanMed Clinical Care Rounds/ Educational Activity

2. CanMed Technical Skills Round*

1. Bedside Ward Round2. Sitting Ward Rounds3. Short Case Discussions4. Long Case Presentations 5. Actual Patient & Simulation –

Technical Skill Lab Training6. Videos/Multimedia

In-training evaluation reports Mini-clinical evaluation

exercise (mini-CEX) Objective structured clinical

examinations OSCE Multi-source feedback

Critical appraised topic (CAT) Progression tests Portfolio Objective structured

assessment of technical skills (OSATS)

Logbooks Simulation

Establish and maintain clinical knowledge appropriate to theirpractice

Educational Activities Academic half-day teaching Morning Meetings Ward Rounds Grand rounds Case presentations Seminars Review courses Conferences/Symposia Exit Rounds EBM Rotation Teaching Workshops &

Presentations Literature Searching/PICO

Exercises Critical Appraisal Journal Club

In-training evaluation reports Written examinations

(multiple choice and open-ending)

Standardized oral examinations

Standardized Patient Examinations

Chart-stimulated recall oral examinations

Logbooks & Rating of attendance, presentations, literature searching/ Journal Club-CAT exercises

Medical Expert



Continuous professional Development

Learning Activities Individual or group learning activities that occur on a regular or day to day basisSelf-Assessment Programs

Out 0f Hospital : Conferences Workshops Courses Subscription to

Knowledge update electronic resources

In Hospital : Grand rounds (1hr/week ) Journal clubs Morning report Ward rounds Half day activities Residents Knowledge

Database Exit Rounds MCQs/Multimedia

Sessions & QuizzesPersonal: Medical Knowledge

Assessment Program (MKSAP)

Cecil's MCQs 's MCQs

Multi-source Feedback

Short Answer Questions

MCQ

Scholar

ScholarSub-competency Recommended Activity Recommended Method of

DeliveryRecommended Assessment Tool

Evidence-Based Medicine Asking (Relevant) Questions (PICO Exercises)

Acquiring Knowledge (Literature Searching Exercises)

Appraisal (Critical Appraisal Exercises)

Applying Knowledge (Knowledge Translation exercises)

Assessment of EBM Process

EBM Rotation Regular Educational

Prescriptions Activity PICO Exercises 5As in Journal Club,

Morning Meetings and Ward Rounds

Computer Lab Training Sessions

Developing Evidence-based Policies, Pathways and Guidelines

Multi-source Feedback Short Answer Questions MCQ Objective structured

assessment of technical skills (OSATS)

Teaching Presentation Skills Time Management

Skills Personal Performance

Skills Teaching e.g.

supervision, mentoring

Courses Workshops

Multi-source Feedback

Research Research & Biostatics Creating Research

Ideas/Banks Writing research

Proposals Funding your Research Writing Papers & Thesis Publishing Research

Courses Workshops Research Rotation Mandatory Research

Multi-source Feedback Short Answer Questions MCQ



Documentation The Complete H&P Writing Follow-up

Notes (SOAP) Writing Handing-

Over/Sign-out Notes Writing/Dictating a

Discharge Summary Writing/Dictating a

Medical Report

Lectures Small groups (PBL) Role modeling

Daily progress note assessment.

Review of dictation summary.

Consultation skills Writing a Consultation Letter

Verbal Consultation Skills

Lectures Small groups Role modeling

Direct observation OSCE Simulation

Counseling skills/ Breaking bad news (verbal and non-verbal )

Effective Rapport Empathy Psychosocial Skills

Lectures Small groups Videos Bedside teaching Role modeling

Direct observation OSCE Simulation Standardized Patient

Examination Patient Survey

Communicator

Sub-competency Recommended Activity

Recommended Method of Delivery


Clinical Care Collaboration

Leadership skills Multidisciplinary/

Interdepartmental Care Dynamics

Resolution of Interpersonal Conflicts

Discharge Planning

Lectures Small groups

(PBL) Role modeling

Daily progressnote assessment.

Review of dictation summary

Written tests (short-answer questions, essays)

In-training evaluation reports (ITERs)

Objective structured clinical examinations (OSCEs)

Simulation Multi-source

feedback

Community Patients’ Friends Societies & Support Groups

Government Bodies Collaboration


International Research Collaboration

Quality of Care Collaboration


Collaborator



Health Care Organization, structure and financing of the healthcare system

Lectures Multi-source feedback and Peer Evaluation

Simulation Portfolio Direct Observation

Effective Healthcare System/Quality Improvement

Committee membership e.g. M&M committee

Audit & Quality Workshops & Presentations

Economic Appraisal Workshops

Implementation of Change Strategies

Discharge Planning

Career Development Job Searching Writing curriculum

vitae, personal statements and covering letters

Interview Skills

Lectures Workshops Small groups

Administrative Development

Physician Roles Time Management

Skills Leadership Skills

Lectures Workshops Small groups

MANAGER



Patient Healthcare Needs:

Patient Education (disease, drugs, etc)

Health Promotion (lifestyle, social, economic, psychological, environmental)

Disease Prevention e.g. Vaccination, Chemoprophylaxis, Screening)

Timely Referrals e.g. Medical Consultations, Home Health Care

Clinical care Activities e.g. Ward Rounds, Morning Meetings etc

Lectures Workshops

Essays Short-answer

questions (SAQs) Direct observation

and In-Training Evaluation Reports (ITERs)

Objective structured clinical evaluations (OSCEs) and standardized patients

Multi-source feedback and peer evaluations

Portfolios

Community Health Needs

Membership of Patient’s Help Groups

Community Care Service/Participation

Community Service Rotation

Workshops Conferences

Population Determinants of Health

Health Ministry Service/Participation

Population/Public Campaigns

Community Service Workshops Conferences

HEALTH ADVOCATE

Sub-competency Recommended Activity

Recommended Method of Delivery


Ethical Practice Ethical Care Ethical dilemmas

Workshops Role modeling Clinical Activities

(ward Round, Morning Meetings etc)

Direct observation In-training

evaluation reports (ITERs)

Multi-source feedback

Portfolios

Professional Practice

Codes of Conduct Professional

Behaviour Islamic Moral

Values Legislative Regulation

Workshops Role modeling Clinical Activities

(ward Round, Morning Meetings etc)

Self-Care Physical & Psychological Health

Stress Management

PROFESSIONAL

Necessary Structures• Committed Leadership• CanMEDS Skilled Faculty• CanMEDS-Based Curricula• Simulation Lab• Education Department

Both Junior and Senior staff training Educationalists members

Current and Future Plans CanMEDS-skilled Faculty.

Outcome: Awaits: CanMEDS Cttee restructuring PLUS a Train-the-

Trainers program: Vertical TTT Program: inclusive of Senior Faculty and

Residents Horizontal TTT Program: Compulsory longitudinal

program

Restructuring the System of Training: The CanMEDS Subcommittee

Outcome: Expansion of Cttee membership to 6 Seniors

(Consultants/Assistants) and 1 Educational Specialist (from the College of Medicine) PLUS 12 Residents from R1, R2 and R3.

Restructuring the System of Training: The CanMEDS Training Proposal (Syllabus)

Outcome:

The CanMEDS Training Proposal is rich in its content and will serve as a reference at least for the initial drafting of the TTT educational curriculum (together with other resources as outlined below).

The CanMEDS Champions: Faculty &Resident Outcome: The new number of members will “set in motion” the

practical creation of skilled Champions (from Seniors and Residents) by facilitating the establishment of “ Competency-focused Micro Teams” e.g. Micro-team for the Communicator Role, Micro-team for the Professional Role etc.

The CanMEDS Champions: Faculty &Resident Outcome: Each micro-team will consist of 1 Senior and

2 Residents at different levels of training.

R1 Resident

Consultant

R2

Competency

Champions Micro-Team

Train-the-Trainers Workshops Outcome: Each micro-team will be entrusted with the task of

building a full-curriculum for their allocated competency. Material (handouts, power-point etc) prepared would have to be presented to the committee and approved for inclusion in the TTT workshop.

Resources from KAMC CanMEDS Collaborating centre CD as well as from the RCP of Canada website may provide the micro-teams with useful material.

RCP of Canada CanMEDS best practice:

http://www.royalcollege.ca/portal/page/portal/rc/canmeds/whatworks

http://www.royalcollege.ca/portal/page/portal/rc/canmeds/whatworks

5%Method of Learning

Experiential Learning:

Bloom's Taxonomy of Learning Objectives

Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7.

Knows

Shows how

Knows how

Does

Pro

fess

iona

l aut

hent

icity

Cognition

Behaviour

facts and concepts

problem solving

skills labs

practice

TRAINING OF COMPETENCIES: MILLER

Knowledge

(Concepts)

Understanding

Practice

Reflection

Assessment

THE 5 PHASES OF EFFECTIVE TRAINING

Session Knowledge Understanding Skill/Practice Extras for the Skill

Reflection Assessment

Documentation:Follow-up NotesSign-Out/Handing Over notes

Lecture: SOAPSign-out

Case Discussion/Clinical Vignettes

Experiential Learning:Case Scenarios

Video on SOAP/Sign-out

Ad-hoc Discussion Session

Documentation:Consultation(Verbal/Written)

Lecture Case Discussion/Clinical Vignettes


Video on Consultation Skills


Documentation:-Discharge Summary-Medical Report



(Old Discharge Summaries)


Counseling skills/ Breaking bad news (verbal and non-verbal )

Lecture/SPIKES Cognitive Aid


Experiential Learning:Role Playing

Video on breaking Bad News/ Counseling


Presentation Skills:PowerPoint

Lecture Examples of “good” and “bad” presentations

Videos

Train-the-Trainers 3Ts in Communicator Role: See-One-Session SOS



Leadership Skills

Lecture: What?How?



Video on Leadership


Team Building Skills



Video on Team Building Skills


Resolution of Interpersonal Conflicts Skills



Video on Conflict Resolution


Discharge Planning Skills


Experiential Learning: Case Scenarios

Story Telling


Train-the-Trainers 3Ts in COLLABORATOR Role: See-One-Session SOS



Career Management Skills

Lecture: Job SearchingWriting curriculum vitae, personal statements and covering lettersInterview Skills

Experiential Learning: proposing and completing a career move

Role Playing: Interview skills Video on good Interview skills


Time Management Skills



Video on Time Management Skills


Quality Management/Improvement Skills

Lecture : What is QM? Audit?Management of Change?


Experiential Learning:Case ScenariosAudit Exercise


Discharge Planning Skills


Experiential Learning: Case Scenarios

Story Telling


Health Organizations/Finance & Physician Roles

Lecture

Train-the-Trainers 3Ts in Manager Role: See-One-Session SOS

Restructuring the Process of Training

Restructuring the Process of Training and Assessment:

1. CanMEDS Competencies “Teaching Moments”.

2. Competency Structured Topic Presentation.

3. Competency Structured Morning Meeting discussion format.

4. Competency structured Ward Round.

CanMEDS Competencies “Teaching Moments” Highlighting in an “Explicit” manner a CanMEDS

competency whilst dealing with a patient care issue e.g. Medical Expert with H&P Collaborator role when referring a patient Scholar when discussing New evidence, NNT etc Advocacy when referring to Home Health Care etc Manager when dealing with system/process improvement Communicator when breaking bad news etc Professionalism when discussing ethical issues etc

Competency Structured Topic Presentation

Bronchial Asthma

Medical Expert History & Physical Exam Essential Technical Skills (Pulse

Oximetry, Peak Flow meter Recording, Use of Inhaler Devices etc)

Essential Investigations/Imaging Emergency Medical Interventions Monitoring Response to Treatment Discharge Planning/Criteria for

Discharge

Communicator Presentation Skills Feedback Counseling skills/ Breaking bad

news

Collaborator Essential Consultations & Referrals e.g. Pulmonology, Pulmonary Educator, Allergologist etc

This Novel Method of Presentation may assist in realizing a more competency-directed clinical trainingand decision-making process, and in drafting a comprehensive,high-quality management plan for every patient.

Competency Structured Topic Presentation

Bronchial AsthmaAdvocate Essential Educational input

regarding Asthma and its treatment, Self-management Plans etc

Risk Factors Counseling e.g. smoking, allergens

Referral to Patients’ Friends Societies & Support Groups

Manager Interventions to reduce Cost of care/Length of stay

Quality Indicators/Audit of Asthma care

Economic Comparisons of various interventions

Scholar Evidence-based resources for Asthma guidelines, protocols

Asthma Societies Websites Update on new studies on

Asthma

Professional Ethical challenges in Asthma e.g. Intubation or not, Unorthodox treatments, Refusing steroid therapy etc

80 Yr old, bed-bound with AF , hypertension and DM. Was admitted with a new stroke ?embolic.

As a medical expert: were the H & P up to CanMeds standard-structured, comprehensive, relevant etc.As a Communicator: Presentation skill? How did he/she convey the news to the family? Empathy & support?As a Collaborator: Were the necessary referrals appropriate and professionally arranged?As a Manager: Quality of care, cost of Care: Time and resource utilization are appropriate?As Health Advocate: Any arrangements with social and other healthcare facilities?As a Scholar: Literature searching exercise on the options of care and preventive strategies for this particular patient.As a Professional: Attitude and behavior observation, discussion of the ethical issues re-anticoagulation, code status, etc

CanMed Ward Round: Explicit Resident Training

Restructuring the Process of Training and Assessment:

5. Competency-enhancing Cognitive Aids like the 5S Cognitive Aid.

6. End-of-Rotation Competency Appraisal Form (ERCA).

7. Others: Using CanMEDS headings in Clinical Pathways etc

8. Simulation Lab. (as an essential structure for fulfilling many aspects of training and assessment in the CanMEDS competencies).

End-of-Rotation Competency Appraisal Form (ERCA). Resident is requested to:

1. Select specific patient care issues

2. Itemize them and

3. Illustrate the selected CanMEDS competency intervention that was used to deal with each of them.

End-of-Rotation Competency Appraisal Form (ERCA). An example courtesy of

Dr Raed Al Enazi R1.

Patient Diagnosis &

MRN or Work-related

Difficulty

Competency

Reason(s) for selecting this

specific patient/problem

Suggested Specific Competency Input(s)/Action(s) to incorporate for the selected patient/problem

Recommendations for future use in

other similar patients/problems if

applicable

Deteriorating level of consciousness

Medical Expert

Patient with prolonged INR (>9), LVF, CKD, DM. septic

foot ulcer: many possible reasons!

Using the 3Rs to diagnose the cause: Rules of Thumb, Red Flags, Rule-out-worst Scenario

Use a bed-side check-list for patients whose level

of consciousness deteriorates during their

in-patient stay.

Advanced Cholangiocarcinoma

Communicator

Breaking bad news and discussing

putting the patient no code with the

family

Using SPIKES mnemonic for breaking bad newsProviding written material on what no-code meansInvolving Religious affairs department

Policy and Procedure for NO Code patients with

both Physician and Family educational

inputs, written material etc

Patient Diagnosis &

MRN or Work-related

Difficulty

CompetencyReason(s) for

selecting this specific patient/problem

Suggested Specific Competency

Input(s)/Action(s) to incorporate for the selected

patient/problem

Recommendations for future use in other

similar patients/problems if

applicable

Elderly patient with dementia, Parkinsonism, and bed-bound.Admitted with aspiration pneumonia.

CollaboratorPatient refusing discharge (2 months in the hospital)

Multidisciplinary meeting inclusive of MRP, HHC, neurology, social services and family

Earlier involvement of care givers in the discharge

process/discharge planning.

17 year old female patient with acute sickle cell crisis and acute chest syndrome

Health Advocate

Patient due to get married

Educating patient on her diseasePreventative interventions including vaccinationPre-marital counseling and husband screening for genetic disease

Hospital wide genetic disease patient and family education support team,

procedure and policy

Patient Diagnosis &

MRN or Work-related

Difficulty

CompetencyReason(s) for selecting

this specific patient/problem

Suggested Specific Competency Input(s)/Action(s) to incorporate for the selected patient/problem

Recommendations for future use in other similar

patients/problems if applicable

Ward-round Time ManagerWard round taking too

long

Time management skillsUse Lean system to make work more efficient (study areas of time wastage)

Develop a policy/procedure to Re-organize the ward

round

Diuretic Resistant fluid overload

ScholarHow to manage such

patients?

Literature searching for best available evidence for dealing with this problem.

Patient is unhappy with the provided medical care.

ProfessionalPhysician-patient-family conflict with its negative impact on patient care

MRP-Family conferenceInvolving trustworthy ColleaguesInvolving patient relations department

Policy-procedure for conflict resolution

The CanMEDS Sub-committee Important and worthwhile achievements Novel models: opportunity for educational

research Ahead of other Departments Pending actions:

(3Ts) need for administrative and faculty support. ? Educationalists

Acknowledgement Dr Ali Al Khatahmi Dr Esam Al Banyan Dr Mohammed Al-Qahtani * Dr Thari Al-Anazi * Dr Abdulla Al Gwizani * Dr Mahfouz Farouqi Dr Marwan Al-Kishi Dr Thamer Al-Anazi Dr Hadi Kuriry Residents

Incorporating CanMEDS in Residency Training Final 1

Health & Medicine

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