Overall Goals & Objectives

Regular evaluation of a resident's knowledge, skills, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. In addition, Competence By Design (CBD) was implemented in July 2018. Under CBD, residents must be observed and document Entrustable Professional Activities (EPA) to receive regular feedback and demonstrate achievement of competence for their stage of learning. EPA observation should occur, on average, at least twice per week.

The resident's knowledge and skills in the Medical Expert domain will also be evaluated in an oral examination (R2), OSCE (R1, R2 and R3), Royal College Examination practice sessions (R3), and completion of the AMBOSS exam (R1, R2 and R3). Residents are expected to demonstrate competence to continue to move forward in CBD stages.

R1 Interpreter

After the first year of residency training, at the end of Foundations of Discipline, the residents will demonstrate the characteristics of an interpreter for common clinical presentations. At this stage, residents should be able to do the following:

•  Perform a complete and reliable history and physical examination, recognizing the normal from the abnormal.

•  Prioritize and analyze patient problems. Create and prioritize a working diagnosis and differential diagnosis for high priority problems

•  Select appropriate investigations in a logical sequence, recognizing normal from abnormal results, and their significance.

It is expected that R1 residents will complete the Transition to Discipline stage within the first two months of residency, and the Foundations stage by the end of the R1 year.

R2/R3 Leader → Educator

During the second and third year of training, residents complete the Core of Discipline stage of training, gaining more experience during that time and becoming more comfortable and competent in a senior role. After the second year of residency training, the resident should demonstrate the characteristics of a leader for common clinical presentations and interpreter for uncommon clinical presentations. At this stage, residents should be able to do the following:

•  From a comprehensive problem list, synthesize an effective diagnostic and therapeutic plan, and establish appropriate follow‐up.

•  Demonstrate effective consultation skills, presenting well‐documented assessments and recommendations both verbally and in writing.

•  Act on problems when most appropriate

•  Customize a plan according to patient circumstances and preferences

•  Hallmark: Independent, efficient and appropriate use of time, leading to succinct but accurate documentation of key points and actions.

•  Procedures (from CD 5): thoracentesis, paracentesis, lumbar puncture, arthrocentesis, airway management and endotracheal intubation, and arterial line catheter

After the third year of residency training, the resident will demonstrate the characteristics of an educator for common clinical presentations and manager for uncommon clinical presentations. At this stage, residents should be able to do the following:

•  Be knowledgeable in both common and uncommon diseases.

•  Critically appraise current medical evidence to specific patients, understanding the uses and limits of that evidence.

•  Actively respond to uncertainty

•  Employ efficiency strategies to allow back-checking

•  Effectively mentor others in diagnostic reasoning

•  Procedures (from CD 5): thoracentesis, paracentesis, lumbar puncture, arthrocentesis, airway management and endotracheal intubation, and arterial line catheter

The resident's knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts and skills in this field as the resident's clinical training progresses.

Communicator

The curriculum is structured to occur in the patient‐care context through the application of the principles of verbal and written communication with patients, families, and in discussions and presentations with colleagues and health‐care professionals. Residents also make regular presentations with feedback in academic half days and other educational events.

Communication skills instruction is a part of academic half day. The two‐week CanMEDS rotation in third year provides a daily forum for group discussion and analysis of methods and approaches to better communicate with patients, families, and colleagues. Case formulation skills are modeled and refined throughout residency, but especially in the Medicine Senior rotations. Difficult conversations such as disclosure of diagnosis, obtaining consent, breaking bad news, medical error, and family conferences are regularly available in most clinical rotations. In terms of written communication skills, in the MCT rotation, residents submit a written reflective essay, and in Senior ambulatory blocks, residents should hone their skills in the preparation of consultation letters using dictated consultations or the Electronic Medical record.

Regular evaluation of a resident's knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. Directly observed patient interviews occur in observed EPAs, oral examinations, and OSCEs.

As a result, residents should demonstrate competency in the following elements of the communicator domain:

•  Establish rapport and trust in the doctor‐patient relationship. This includes respect for diversity, overcoming language and cultural differences, empathy, listening, non‐verbal communication,

•  Establish rapport and trust in the team setting, but with colleagues and other professionals or team members in the care setting. This includes shared decision making, concordance, mutual understanding, integrity, flexibility, effective listening, respect, and appropriate documentation

•  Elicit information for patient care through history taking, physical examination, chart review, and the use of informatics.

•  Express accurate clinical findings, both verbally and in writing, in a manner that demonstrates a sound knowledge of the underlying illness scripts, and emphasizes the elements most likely to lead to a correct diagnosis and plan of action.

•  Effectively communicate sensitive issues such as breaking bad news, addressing end‐of‐life issues, disclosure of error or adverse events.

•  Conduct family and team conferences, engaging patients and families in developing plans that reflect their health care needs and goals.

•  Document and share written and electronic health information about a medical encounter to optimize clinical decision-making, patient safety, confidentiality, and privacy.

The resident's knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts in communication as the resident's clinical training progresses.

Collaborator

The curriculum is structured to occur primarily through the patient‐care context, where residents are collaborative members of multidisciplinary and interdisciplinary health‐care teams. The CanMEDS rotation includes group discussion on the role of the physician on clinical teams, and the need for close cooperation and collaboration with other services and other members of clinical teams. Also, in some settings such as the University Hospital, residents may attend the Interprofessional Educational Rounds to gain better insight into the scope of practice of allied health care professionals. Participation in daily "rapid rounds" in most inpatient settings reinforces the roles of each team member. Conflict management skills are especially needed in high stakes and emotionally charged environments where they represent their attending physician, in collaboration with various stakeholders, to optimize outcomes for patients. Commonly this occurs in the senior years on Critical Care, ED consult and CTU Teams rotations. In virtually all in-patient rotations, there is a collaborative duty to ensure continuity of care using strategies such as a structured handover. The SBARR model is taught in R1 during Boot Camp and should be constantly reinforced through daily practice on inpatient rotations.

Regular evaluation of a resident's knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. As a result, residents should demonstrate competency in the following elements of the collaborator domain:

•  Understand and describe the expertise and role of all of the members of an interdisciplinary team.

•  Participate as a collaborative member of the health‐care team, demonstrating shared analysis and decision making skills and contributing appropriate expertise and leadership to the team.

•  Develop a care plan for patients, based upon the collaboration among the different members of the health‐care team.

•  Constructively negotiate solutions to challenging clinical, psychological or social issues that arise in patient care or learning.

•  Effectively resolve conflict

•  Recognize personal limitations and seek proper assistance in the best interests of patients.

•  Participate in effective handover

The resident's knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced attitudes and skills involved in being a collaborator as the resident's clinical training progresses.

Regular evaluation of a resident's knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. As a result, residents should demonstrate competency in the following elements of the manager domain:

•  Utilize personal resources effectively, including time and personal capacity, to balance patient care, learning needs, and outside activities.

•  Demonstrate the ability to prioritize and triage in the context of competing demands.

•  Allocate health‐care resources wisely.

•  Work efficiently in a health‐care organization including engagement with secretarial staff, program assistants, managers, leaders and other stakeholders.

•  Utilize information technology to optimize patient care, life‐long learning, and other activities.

•  Recognize the business and financial skills necessary for a successful medical practice.

•  Take responsibility for delegated tasks and properly delegate when appropriate.

•  Demonstrate leadership in professional practice

•  Contribute to the improvement of health care delivery in teams, organization, and systems

•  Engage in stewardship of health care resources

The resident's knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced attitudes and skills involved in being a leader as the resident's clinical training progresses. It is recognized that much of the skill development in this domain will continue into the fourth year of residency training and into practice.

Health Advocate

The curriculum is structured to occur primarily through the patient‐care context. It is in this context that the resident participates in the day‐to‐day care of inpatients and outpatients, as an advocate for the individual patient and society as a whole. In the CanMEDS rotation, residents confront scenarios that bring into conflict the physician’s duties to advocate for their patient’s autonomy and beneficence with distributive justice when there are limited resources. Residents are encouraged to plan international electives which emphasize global health issues. Residents may also schedule a selective in Inner City health (ARCH clinic), or in other high yield rotations such as Geriatric Medicine, Infectious Diseases, and Palliative Care, as well as outreach rotations outside of Edmonton, including Yellowknife.

Regular evaluation of a resident's knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. As a result, residents should demonstrate competency in the following elements of the health advocate domain:

• Identify the important determinants of health affecting patients. More specifically, the resident will be able to educate patients about long‐term healthy behaviour and preventive health care.

• Contribute effectively to improved health of patients and communities.

• Use authority and influence responsibly to help advocate for the best interests of patients.

• Appreciate the existence of global health advocacy initiatives for elimination of poverty and disease.

• Participate in quality improvement exercises in the context of patient care.

• Understand fiduciary duty to care

• Perform an assessment of decision making capacity, and help find an ethical balance between a patient’s expressed choice and their best interests.

The resident's knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced attitudes and skills involved in being a health advocate as the resident's clinical training progresses.

Scholar

The curriculum is structured to occur through regular journal clubs, academic half‐days, subspecialty teaching sessions, and supervised research projects. The resident will have regular opportunities to present clinical cases and topic reviews during academic half day and at various clinical conferences. Teaching of junior learners is evaluated formally in both clinical and classroom settings using structured instruments.

A generous travel fund for all residents allows participation in conferences and the purchase of tools and materials that reinforce their learning. In particular, our program advocates study with self-assessment. For written exams, we recommend that personal reading be paired with on-line programs which provide both information and opportunities to test knowledge such as NEJM Knowledge Plus and MKSAP 17 Tracker. Daily reading around cases starting with a "blank page" approach and ending with a personal note to emphasize new knowledge is also advocated.

Regular evaluation of a resident's knowledge, skills, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. Narrative reflection on daily work experiences, and all formative and summative assessments, is supported using our portfolio system. This fosters the habit of reflective practice.

Residents may apply for protected selective time for research, supported by the Resident Research Subcommittee. Residents have the opportunity to present their research work to their colleagues at the annual "Resident Research Day". Presentation of appropriate work at provincial, national, and international conferences is strongly encouraged and supported. Critical appraisal skills are taught in academic half day and reinforced in journal clubs.

As a result, residents should demonstrate competency in the following elements of the scholar domain:

•  Apply the principles of critical appraisal to sources of medical information, in the clinical, research, and educational contexts.

•  Apply knowledge in clinical practice.

•  Facilitate the learning of patients, students, residents, and other health‐care professionals.

•  Contribute to the development of new knowledge.

•  Develop and implement a personal strategy for lifelong learning and maintenance of competence.

•  Foster skills in self‐assessment and directed learning.

The resident's knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts in clinical epidemiology, teaching, and research as the resident's clinical training progresses.

Regular evaluation of a resident's knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. As a result, residents should demonstrate competency in the following elements of the professional domain:

•  Deliver quality care with integrity, honesty, and compassion.

•  Show appropriate personal and interpersonal behaviours.

•  Practice medicine ethically, consistent with the obligations of a physician.

•  Maintain personal and family health and well‐being by keeping in check the demands of residency training while seeking support when required.

•  Offer assistance to respect a professional obligation to peers and society.

•  Maintain a commitment to excellence and mastery of the discipline of medicine.

•  Exercise facility in the application of bioethical principles and theories.

•  Disclose personal error and adverse events.

The resident's knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced attitudes and skills involved in being a professional as the resident's clinical training progresses.