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      Residents: admissions, training and assessment

      editorial
      Canadian Medical Education Journal
      University of Calgary, Health Sciences Centre

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          Abstract

          Undoubtedly, residents play a very important role in the healthcare system of most countries. The process of admission of medical trainees into specialties, residency training and their assessment are key determinants of the future of healthcare. In Canada, according to the 2014–15 data, there were 13,439 residents (excluding Fellows) distributed in 42 specialties/sub-specialities.1 Every year, there are 3,280 positions in Canada. About 10% of these residents are International Medical Graduates (IMGs) or Canadians studying abroad (CSAs). Residents are subjects of various investigations exploring areas such as sleep deprivation, stress,2 medication errors to differences between Canadian Medical graduates (CMGs), IMGs and CSAs that can help with decisions of policy makers.3 Here I dwell on a two interesting examples of studies using residents as subjects. Philips and Barker who systematically examined the occurrence of fatal medication errors over 25 years in the US attribute a significant spike in medication errors in July to the entry of a new cohort of medical residents.3 Can changes in medical education have an impact on such medication errors? While this needs to be investigated, better orientation of final year medical students for entry into residency, closer supervision of new residents, and training of supervisors on providing feedback to residents are some measures that ought to be seriously considered. The introduction of Competency by Design (CBD) by the Royal College of Physicians and Surgeons is definitely an important step in this direction.4 A recent study by Curtis and Dube looked at the characteristics of CMGs, IMGs and CSAs in an era where measures are being taken to alleviate physician shortage.5 IMGs make up about 25% of practicing physicians in Canada. However, the scenario is changing, with more CSAs applying for residency positions. As of 2014, there were 3600 CSAs. These findings in particular have implications for policy: IMGs are less likely than CMGs to report that they intend to stay and practice in Canada; CSAs are less likely to report their willingness to practice in the region where they completed their residency. CSAs and IMGs are more likely to choose family medicine than CMGs. Given the paucity of residency positions in Royal College specialties, and less inclination of CMGs to choose family medicine, do changes have to be made to admit more CSAs and IMGs to fill family medicine positions? If that is done, how can IMGs be enticed to practice in Canadian regions where physicians are most needed? IMGs and CSAs are less likely to be females. How will this impact the diversity and equality that Canada tries to promote? These are interesting and complex questions that arise from the study. This publication of CMEJ focuses on residents In Canada, the Canadian Resident Matching Services (CARMs), a non-profit, fee-for-service organization, facilitates a fair and transparent process of resident admissions into programs.6 Medical trainees begin the online application process by uploading transcripts and supporting documents along with their ranking of choices of specialties and programs. Individual programs across the country access these documents and based on their criteria, call residents for interviews and upload their ranking of students. CARMs matches the student choices with specialties and programs using an algorithm. The interview process by programs is a vital element to the CARMs process. Sklar et al. explore the differences in scores of applicants to postgraduate admissions using traditional interviews (TIs) and Multiple Mini Interviews (MMIs). While the scores correlate well, the rank order varies. The authors suggest that MMIs and TIs measure different (so called) non-congitive areas.* The Royal College of Physicians and Surgeons and the College of Family Physicians of Canada play are regulatory bodies that oversee the quality of residency training in Canada. Research into the training process and application of educational principles helps promote training quality. In this edition, Guajardo and colleagues examine the effect of inclusion of patient name and image in virtual patient cases on knowledge acquisition. A large part of resident training involves role modeling by preceptors. In Canada, with its wide distribution of population in rural and remote areas, medical schools train students and residents in these areas under the supervision of preceptors. Piggott, Morris, and Lee-Poy examine the facilitators and barriers to engagement of preceptors in distributed medical campuses. There are several barriers that can be addressed by medical schools such as: provision of training of preceptors in being better teachers, ensuring that preceptors in these areas are aware of curricular objectives, among others. Lubitz, Lee, and Hillier look at the perception of residents to the longitudinal integrated curriculum, a form of training provided in mostly rural areas. With the introduction of the CanMEDs roles, residents are trained and assessed using the CanMEDs framework.7 In-training Evaluation Reports (ITERS) is an accepted assessment mechanism that is utilized by most Canadian medical schools. ITERs8 require preceptors to provide feedback to residents and the program using a Likert scale and comments under the categories of Residents as Medical Experts, Communicators, Collaborators, Leaders, Health Advocates, Scholars and Professionals. Patel et al explore the perception of pediatric residents and faculty of using ITERS. There is considerable debate on what is/are the best tool(s) to evaluate each of the CanMED roles. Poulton and Rose review the importance of Health Advocacy in resident training, current attitudes, and issues relating to its evaluation. A large volume of literature exists in relation to the transformation of trainees from novices to experts.9,10,11 Illness scripts are a recognized mechanism that help physicians integrate new incoming information with existing knowledge, recognize patterns and irregularities in symptom complexes, identify similarities and differences between disease states, and make predictions about how diseases are likely to unfold.11 Expert physicians have a wealth of formulated illness scripts that help them make quick and accurate diagnosis. Resident curricula are planned and designed to provide trainees opportunities in various forms to promote formation of illness scripts. In this issue that focuses on residents, Lubarsky and colleagues expand on the script theory to cultivate illness script formation and Phang and colleagues explore the mental mechanisms used by residents to estimate disease probability.

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          Factors associated with mental health status of medical residents: a model-guided study.

          Residency is a stressful period in a physician's development, characterized by long work hours, time pressure, and excessive work load, that can exert negative effects on residents' mental health. Job burnout and negative work-home interference may play a major role in residents' mental health problems. The present study used the job demands-resources model as a theoretical framework to examine the way in which job demands (e.g., workload, emotional demands) and job resources (e.g., supervisor support, job autonomy) were associated with residents' mental health. From a pool of 290 medical residents, 264 (91 %) completed the questionnaires. Applying structural equation modeling techniques, the results showed that greater emotional exhaustion (β = -.65, SE = .09, p < .001) and more work-home interference (β = -.26, SE = .10, p < .05) were related to poor mental health. Specific job demands (i.e., high workload) and particular job resources (i.e., low opportunities for professional development and low supervisor support) were related to poor mental health not directly but only indirectly, via emotional exhaustion or work-home interference. Thus, through work-related emotional exhaustion, the impact of work conditions might be transmitted to and interfere with non-work related domains such as family life, as well as with domain-unspecific aspects of well-being, such as mental health and psychological distress. Implications of the results and suggestions for future research and practice are outlined.
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            'Science', 'critical thinking' and 'competence' for tomorrow's doctors. A review of terms and concepts.

            The recommendations of the General Medical Council in Tomorrow's Doctors renewed efforts to define core knowledge in undergraduate medical education. They also encouraged better use of the medical knowledge base in nurturing clinical judgement, critical thinking, and reflective practice. What then does the medical world understand by 'science', 'critical thinking' and 'competence', given the need to address both growth and uncertainty in the knowledge base and to practise evidence-based healthcare? This review aims to outline the role of these key concepts in preparing undergraduate medical students for professional practice. Specifically, it explores: the fallibility of the 'scientific' foundations of medical practice; the role of understanding and thinking in undergraduate medical education; the need for a broad interpretation of competence and its relationship to transferability, and the nature of clinical judgement. Tensions are seen to lie in the varying interpretations of clinical decision making as art or science; the varying characterizations of the nature of skilled performance in the novice, the competent and the expert practitioner, and the varying reactions to the acceptability and usefulness of 'meta-' concepts in capturing the essence of professional practice. Habitual self-conscious monitoring of mental processes may be the key to the flexible transfer and application of knowledge and skills across the contexts, characterized by uncertainty and incomplete evidence, for which doctors must be prepared.
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              The CANMEDS assessment tools handbook: en introductory guide to assessment methods for the Canmeds competencies

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                Author and article information

                Journal
                Can Med Educ J
                Can Med Educ J
                Canadian Medical Education Journal
                University of Calgary, Health Sciences Centre
                1923-1202
                2015
                11 December 2015
                : 6
                : 2
                : e1-e3
                Affiliations
                University of Saskatchewan, Saskatoon, Saskatchewan
                Article
                cmej0601
                4795076
                27004071
                da9f24dc-e93e-4b29-a25c-b3577f21df7c
                © 2015 Premkumar; licensee Synergies Partners

                This is an Open Journal Systems article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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