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 MBBS Chairman, CanMEDS Syllabus Subcommittee Department of Medicine, KAMC,KSA
Nov 22, 2014
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
12
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
Sub-competency Recommended Activity Recommended Method of Delivery
Recommended Assessment Tool
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
Sub-competency Recommended Activity Recommended Method of Delivery
Recommended Assessment Tool
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
Recommended Assessment Tool
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
Lectures Small groups
International Research Collaboration
Quality of Care Collaboration
Lectures Small groups
Collaborator
Sub-competency Recommended Activity Recommended Method of Delivery
Recommended Assessment Tool
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
Sub-competency Recommended Activity Recommended Method of Delivery
Recommended Assessment Tool
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
Recommended Assessment Tool
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
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
Experiential Learning:Case Scenarios
Video on Consultation Skills
Ad-hoc Discussion Session
Documentation:-Discharge Summary-Medical Report
Lecture Case Discussion/Clinical Vignettes
Experiential Learning:Case Scenarios
(Old Discharge Summaries)
Ad-hoc Discussion Session
Counseling skills/ Breaking bad news (verbal and non-verbal )
Lecture/SPIKES Cognitive Aid
Case Discussion/Clinical Vignettes
Experiential Learning:Role Playing
Video on breaking Bad News/ Counseling
Ad-hoc Discussion Session
Presentation Skills:PowerPoint
Lecture Examples of “good” and “bad” presentations
Videos
Train-the-Trainers 3Ts in Communicator Role: See-One-Session SOS
Session Knowledge Understanding Skill/Practice Extras for the Skill
Reflection Assessment
Leadership Skills
Lecture: What?How?
Case Discussion/Clinical Vignettes
Experiential Learning:Case Scenarios
Video on Leadership
Ad-hoc Discussion Session
Team Building Skills
Lecture Case Discussion/Clinical Vignettes
Experiential Learning:Case Scenarios
Video on Team Building Skills
Ad-hoc Discussion Session
Resolution of Interpersonal Conflicts Skills
Lecture Case Discussion/Clinical Vignettes
Experiential Learning:Case Scenarios
Video on Conflict Resolution
Ad-hoc Discussion Session
Discharge Planning Skills
Lecture Case Discussion/Clinical Vignettes
Experiential Learning: Case Scenarios
Story Telling
Ad-hoc Discussion Session
Train-the-Trainers 3Ts in COLLABORATOR Role: See-One-Session SOS
Session Knowledge Understanding Skill/Practice Extras for the Skill
Reflection Assessment
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
Ad-hoc Discussion Session
Time Management Skills
Lecture Case Discussion/Clinical Vignettes
Experiential Learning:Case Scenarios
Video on Time Management Skills
Ad-hoc Discussion Session
Quality Management/Improvement Skills
Lecture : What is QM? Audit?Management of Change?
Case Discussion/Clinical Vignettes
Experiential Learning:Case ScenariosAudit Exercise
Ad-hoc Discussion Session
Discharge Planning Skills
Lecture Case Discussion/Clinical Vignettes
Experiential Learning: Case Scenarios
Story Telling
Ad-hoc Discussion Session
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