In the 21st century, postgraduate residency training programs must ensure that their graduates master a series of core competencies to better respond to clearly identified societal needs. Although formulated differently, the core competencies of both the Accreditation Council for Graduate Medical Education (ACGME)1 in the United States and the CanMEDS framework of the Royal College of Physicians and Surgeons of Canada (RCPSC)2,3 describe a whole spectrum of professional competencies that residents must develop. The RCPSC has organized these essential competencies under seven roles2,3: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. Ensuring proper training early in the residency is a major challenge because this framework of core competencies involves new domains of formal teaching and clinical supervision, thus requiring extensive faculty development.
In Canada, where all postgraduate programs are the responsibility of the schools of medicine, the development of such a program is a faculty-wide preoccupation. This was the case at Laval University, where most of our 33 specialty residency programs have scarce financial and faculty resources, sometimes few residents, scattered clinical resources (seven midsize hospitals), and mostly volunteer clinical supervisors who have a limited sense of belonging to the academic program. Like all schools of medicine, we felt responsible for supporting our specialty programs to ensure that residents had a broad-based introduction to all competencies and an overall understanding of how their professions integrate these competencies into their practice.
The literature about core competencies focuses more on methods of assessment and implementation of core competencies in a specific specialty program than on training for competencies.4,5 Some interventions are described, but most involve a single competency, for example, training programs in ethics, communication, or professionalism. These initiatives have included a variety of content areas and strategies, especially in professionalism.6,7 Sound evaluation of some has demonstrated their efficacy.8
Reports of training programs for all competencies together, however, are scarce. A few initiatives have involved simultaneous training for more than one competency, for example, completing Web-based modules9,10 for each of the six ACGME core competencies or grouping some of them into central themes.11 Such teaching programs provide in-depth training for a combination of competencies, but they do not offer an integrated approach to all competencies. Further, most of these programs are concerned with a single specialty. A few reports describe initiatives of group residents from different specialty programs: McGill University's program12 on professionalism, the Medical College of Wisconsin's one-day orientation program13 that provided 245 junior residents with an integrated perspective on core competencies, and the University of Utrecht's plan,14 involving a series of teaching sessions on various competencies throughout the residents’ five years of training.
At Laval University, we responded to this challenge with a unique formula: an integrated one-month multispecialty rotation called Introduction to CanMEDS Core Competencies. To our knowledge, no other school of medicine has implemented such an intensive program that covers all seven CanMEDS roles for junior residents from multiple specialty programs. In this article, we describe key features of the pilot program.
In 2002, after the RCPSC's 1999 accreditation report, the associate dean of postgraduate affairs at Laval University suggested a one-month classroom rotation to teach the basics of the CanMEDS roles to residents from various specialties simultaneously. Previously, there had been local positive experience with a monthlong classroom and lab rotation in the surgical specialties, but there also had been unsuccessful experiences of evening courses gathering residents from various specialties around ethics or critical appraisal. The associate dean formed a working group to develop the curriculum, and he later appointed a coordinator and an educational consultant to implement this project, with a six-month time frame to achieve this endeavor. The pilot program, which we describe below, took place from February 9 to March 7, 2004.
Goals and design
The program consisted of a one-month rotation. There were three overall goals: (1) for residents to develop an understanding of the specialist's competencies as expressed by the CanMEDS roles, (2) for residents to develop many of the competencies involved in the seven CanMEDS roles, and (3) to raise residents’ awareness about the importance of their well-being and life balance. Table 1 summarizes the curriculum; Chart 1 summarizes the rotation schedule.
Most learning activities addressed the second goal, which comprised 12 content areas (Table 1). We used various teaching methods to promote experiential and reflective learning15,16: workshops, role playing, case-based small-group discussions, interactive lectures, personal and group essays, and locally developed Web-based modules, as described in Table 1.
Seven residency programs took part in the pilot project (anesthesiology, dermatology, infectious diseases, internal medicine, neurology, pediatrics, and radiology). More program directors were interested in joining, because the rotation responded to unaddressed learning needs. Because human and space resources were limited for this pilot version, the associate dean selected programs according to their readiness to involve faculty and to the number of residents in the program. Thus, 42 first-year residents were registered for the pilot project of the rotation.
Logistics and resources
For educational purposes, we decided that residents should have at least six months of clinical training before starting this program. To ensure high attendance levels, residents were freed from clinical duties during the day on weekdays for the entire month. However, they continued to provide on-call coverage in the clinics from 5:00 pm to midnight on weekdays, and they did their usual 24-hour shifts on weekends. These details were announced well before the program started. Specialty program directors in the hospitals increased temporary coverage in the clinics by senior residents or, more often, by faculty members.
Resources from the faculty were a project coordinator, an educational consultant (D.S.), part-time secretarial support, and an ad hoc budget of Can $40,000 received from the dean's office. Eleven content-area experts were recruited internally, and one was external to the university. Each was responsible for one content area, for developing adapted teaching sessions, and for training its collaborators. These were 30 part- and full-time, junior and senior, volunteer faculty members from the seven specialties involved in the project, recruited by the program directors. They were ready to learn about a specific content area, share their professional experience, and act as small-group facilitators.
An integrated view of all competencies.
To achieve the first course goal, we developed unique integration sessions to help residents gain an overall understanding of CanMEDS roles, beyond that provided in specific teaching sessions. The learning objectives were (1) to describe the seven CanMEDS roles, (2) to instill appreciation of their importance and the dynamic balance among them within the residents’ specialties, and (3) to understand different manifestations of these roles within the residents’ practice.
To achieve these objectives, residents from the same discipline were asked to reflect on their past clinical experience, interview faculty, and observe senior residents and faculty members at work. Residents then summarized their discoveries in a brief team presentation and a team essay, with four to six residents to a team. In individual personal essays, they each discussed how they thought their discoveries would affect their future training.
During the team presentations on the last day of the rotation, many residents mentioned an improved overall understanding of CanMEDS roles and their unique application to their own discipline. Many emphasized how the rotation had influenced their motivation and their future personal learning objectives. Personal essays went further along this line. For example, an essay by one female resident in internal medicine was written as the diary of a young cancer patient observing life on the ward and commenting on her physicians’ behaviors and attitudes as they assumed the seven CanMEDS roles.
A multispecialty educational strategy.
For both educational and practical purposes, we grouped together residents and faculty from various disciplines. Residents interacted with their peers in large-group (all 42 residents) and small-group activities (10–14 residents, depending on activity), as we ensured a mix of specialties within each small group. We also presented in the learning activities a scope of cases, some generic to all disciplines, others specific to one specialty. For example, during case-based discussions in ethics (see Table 1), residents realized that end-of-life issues presented specific challenges to pediatricians as opposed to anesthesiologists or internists. At the end of the rotation, residents cited this opportunity to interact and socialize with colleagues and faculty from many disciplines as one of the key positive features of the rotation.
An intensive monthlong rotation.
We introduced this daring monthlong format to ensure high attendance and to emphasize the value we placed on early introduction of core competencies in residency training. The intensive delivery (see rotation schedule, Chart 1) ensured continuity within a block of activities (e.g., ethics) as well as a message of cohesiveness between competencies.
Residents’ successful completion of the rotation depended on five criteria: (1) we requested a minimum of 75% attendance. Residents signed in on each half day. (2) Residents must have completed at least 75% of the evaluation questionnaires. They were required to fill out a short satisfaction questionnaire after each half-day session and a different questionnaire at the end of each block of activities in a given content area. (3) Before the end of the rotation, residents had to complete five Web-based modules on critical appraisal of the literature. This material had been recently developed locally.17 Each module required two to five hours of work, with practice exercises and feedback, and a final evaluation which was tabulated by the system's logbook. (4) Successful completion of the team essay and (5) of the individual essay were the last requirements.
Three faculty members (A.R., D.S., and a program director) evaluated the essays. They based their judgment on preannounced criteria: on-time submission; inclusion of a brief summary of their reflective process and activities; definitions and rich descriptions of how the seven roles applied to their own disciplines; clarity; originality; and, for the individual essay, expression of residents’ personal view of the CanMEDS competencies and their application to their role as residents.
Altogether, residents maintained a 95% attendance rate during the rotation and answered 90% of all the half-day satisfaction questionnaires. On the basis of the five criteria, they all successfully completed the rotation, although some residents required prompting to complete their work.
Completed satisfaction questionnaires, as well as end-of-rotation discussions, indicated that residents were very satisfied with each block of activities. Residents were unanimous about the relevance of the program to their training. Many mentioned that they rarely discussed most of its content in clinical settings. They particularly enjoyed the rotation format because it allowed them to participate fully in the program without worrying about clinical duties or external pressures. They highlighted the program's positive effects on their sense of well-being, citing the unique opportunities to reflect on their recent professional experiences and to maintain a balanced lifestyle. They also emphasized the opportunities for socializing, both with residents from other specialties and with faculty members from various disciplines.
At Laval University, the Introduction to CanMEDS Core Competencies program, an intensive, integrated, multispecialty rotation for first-year specialty residents, provided an innovative solution to the problem of introducing these residents to core competencies early in their training. The program was feasible, made good use of our faculty resources, and simultaneously dealt with many core competencies. It was very well received by residents and faculty. Moreover, this program offered three innovations: the one-month and multispecialty formats, and the integrated approach to core competencies.
To our knowledge, this is the first attempt to offer teaching sessions on core competencies in a one-month rotation. The full-time format allowed participants to focus entirely on the tasks at hand. Removing so many residents from their clinical rotations for 20 days throughout the year and ensuring their full attendance and full attention would otherwise be very difficult.
The multispecialty format seemed to have a positive impact on residents’ professional socialization. Their interactions with peers from other specialties lasted much longer than the few days reported in previous studies.12,13
Finally, the integration sessions and related activities in our program promoted residents’ understanding of what it means to be a competent physician. During the closing session, residents’ team presentations and essays indicated that they understood early in their residency the relationship between the core competencies and their overall cohesiveness as well as their application to their future training. Of the few published initiatives9–13 involving teaching various core competencies simultaneously, only Chan et al13 have explicitly mentioned the need to integrate core competencies.
Since the pilot version, the program has been offered on a yearly basis. It now involves 60 residents per rotation, with plans to expand its availability to all specialty programs. Teaching materials and activities were revised and upgraded in response to comments from residents and faculty. We are considering grouping senior residents for training on specific competencies, on the basis of this positive experience and on residents’ requests, for one- or two-day sessions. Faculty development and intraprogram activities are also underway, with the goal of an integrated competency-oriented training.
The innovative aspects of our program should be further assessed. Is our intensive one-month format equivalent to brief, dispersed teaching sessions, or does it offer specific advantages? Our participants insisted that we maintain the format because it reduced competition between formal teaching and the demands of clinical work. Given the residents’ comments, we believe that this training format contributed to their integrated understanding of the core competencies framework. However, this hypothesis needs further testing. The professional socialization phenomenon observed during the rotation, seemingly related to the multispecialty format, also warrants further investigation as a potential basis for the development of competency in collaborative care.
Evaluating knowledge, attitudinal changes, and overall competencies gained by residents during the rotation represents a major endeavor, which we were not able to undertake during this pilot project. Precise assessment of the level of knowledge and skills achieved at the end of the training for each competency would be valuable. However, it would require a complex before-and-after design, or comparison with a control group, combining measurement tools such as written tests, OSCEs, and/or behavior observation on the ward. We were solely able to get a sense of the group's progression, without precise individual measurements. We rely mostly on observational data; for example, we noted a growing sensitivity to issues related to the competencies, and the skills demonstrated as a group in the small-group exercises, though evidence from the evaluation system of the Web-based self-learning modules clearly showed that residents gained critical appraisal skills.
Because any progression in competency over time could be the sole result of professional maturation through the regular residency pathway, long-term evaluation should also be undertaken. Such evaluation should assess the impact of the rotation on residents’ competency in the different content areas, on development of competencies over time, and on their understanding of the profession. Comparative studies between participants and cohorts with no such training or with equivalent content training in a dispersed format would also bring interesting information. We have undertaken a qualitative study of residents’ perceptions of the program's impact one year after their participation in the Introduction to CanMeds Core Competencies pilot rotation.
There is room for improvement in the curriculum as well. We were somewhat limited by a lack of human or financial resources and by a lack of time to develop some content areas (e.g., health advocacy). Our program was standard for all residents, irrespective of their specialty, on the basis of the rationale that its basic tenets were of interest to all. It might be preferable to stream residents from like-minded specialties into certain activities: for example, fewer communication skills and more quality-assessment workshops for technical specialties such as radiology. Finally, formal teaching, however comprehensive, is insufficient for the development of professional competencies. The program should serve as a foundation for more in-depth mastery of competency during their future clinical training.
Nevertheless, the program had numerous positive impacts on our school of medicine. The development and implementation of the curriculum required collaboration between the departments involved, resulting in a growing sense of solidarity among program directors and an increased sense of belonging for participating faculty. The rotation helped each program meet learning objectives that many programs had serious difficulty attaining with individual program resources. Combining resources was both time- and cost-effective. On their return to their clinics, participating residents and faculty were well placed to contribute to the progressive development of a local core-competencies culture. The rotation encouraged faculty development: we offered collaborators initial training in a content area in which they could progressively develop some expertise. They could then contribute with more autonomy to the rotation and become resource persons within their own departments for further teaching of specialty-specific core competencies. Finally, the project was very well received by the RCPSC accreditation team during their April 2005 visit.
However, we had to overcome numerous organizational challenges to successfully implement this curriculum: a tight implementation schedule, modifications to the first-year curriculum of each program to free up participating residents for one month, and a demanding, intensive format for participating faculty and the coordinating team.
From our experience, the following conditions are key to ensure the feasibility of such a rotation:
* strong support from the dean's office
* a centrally administered budget that enables recruitment of resources from any department
* willing local content experts
* financial and faculty development strategies to engage collaborators from all disciplines
* a devoted leader with good support from program directors involved in the rotation
* medical education consultants to support this intensive educational development and parallel faculty development
* a local culture that is education oriented rather than service oriented, to enable all programs to remove their residents from other rotations and on-call duties without undue pressure or negative feedback
Overall, our one-month, multicompetency, multispecialty training format was feasible and well received. It could be of value to other schools of medicine, though it warrants further program evaluation. The challenge remains for postgraduate residency programs to ensure the clinical application of all required competencies until residents’ maturation into professional practice.
The authors are indebted to Dr. Jacques Villeneuve, the project coordinator, who collected all quantitative data, without whose dedication the project would never have been developed. Thanks are due to Drs. Linda Snell and Jean-François Lemay for their critical evaluation of the manuscript. The authors would also like to thank Dr. Richard Gagné, associate dean to postgraduate affairs until 2002, who initiated this project, and Dr. Pierre Leblanc, who succeeded him, and under whose leadership and support the project was implemented. Finally, the authors thank the residents, faculty members, and program directors who graciously participated in the pilot project and provided valuable and always constructive feedback. This paper was prepared with the assistance of Sharon Nancekivell, medical editor, Guelph, Ontario.