Medical Education in Internal Medicine: The Current
Canadian Landscape: A Workshop Delivered
at the 2019 CSIM National Meeting
Daniel Brandt Vegas, MD, MHPE
1
, Leslie Martin, MD, MHPE
1
, Irene W. Y. Ma, MD, PhD
2
, Philip Hui, MD
3
, Ford Bursey, MD
4
1
Department of Medicine, McMaster University
2
Department of Medicine, University of Calgary
3
Faculty of Medicine, University of British Columbia
4
Faculty of Medicine, Memorial University
Author for correspondence: Daniel Brandt Vegas: brandtd@mcmaster.ca
Received: 18 January 2020; Accepted after revision: 25 May 2020; Published: 26 March 2021
DOI: http://dx.doi.org/10.22374/cjgim.v16i1.417
Abstract
The 2019 Canadian Society of Internal Medicine (CSIM) national meeting included a workshop
focused on current topics related to medical education across Canada. The workshop topics
included leadership in education, teaching point of care ultrasound, teaching clinical reasoning,
and using competency-based medical education to design a program meant for the maintenance
of competency of practicing specialists. This article reflects the experience and discussions from
the session, with the goal of stimulating national conversations and collaborations between
CSIM members.
RÉSUMÉ
Le Congrès annuel de la Société canadienne de médecine interne (SCMI) de 2019 comprenait
un atelier portant sur des sujets d’actualité liés à lenseignement médical au Canada. Les thèmes
abordés étaient le leadership en éducation, lenseignement de léchographie au point de service,
lenseignement du raisonnement clinique et lutilisation de l’enseignement médical fondé sur les
compétences pour concevoir un programme de maintien du niveau de compétence des spécialistes
en exercice. Cet article rend compte de lexpérience et des discussions de la séance, dans le but de
stimuler les conversations et les collaborations à l’échelle nationale entre les membres de la SCMI.
Introduction
The mission of the Education Committee of the Canadian Society
of Internal Medicine (CSIM) is to support practicing internists and
trainees with interactive, evidence-based, continuing professional
development (CPD) activities based on their learning needs. In
recent years, there has been an increasing interest within the CSIM
membership to learn more about medical education, especially
with regard to Internal Medicine. For this reason, the CSIM
Education Committee proposed adding a session focused on
medical education to the 2019 annual national CSIM meeting.
Two members of the education committee volunteered
to organize this session in a workshop format, dividing it into
four different topics considered relevant to the current medical
education landscape for Internal Medicine across Canada.
Each topic allowed participants to reflect on and discuss ideas
and experiences, aiming to share perspectives and identify
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opportunities for future development. This approach was used
to stimulate interest and enthusiasm among our membership,
as well as potentially foster a national platform for further
networking opportunities with local and regional interests.
The work-shop serves as a springboard for Canadian Internal
Medicine specialists and trainees with an interest in medical
education to collaborate and share ideas.
We approached clinician educators within our membership
with specific interests and expertise to lead each of the four
topics presented. Dr. Leslie Martin led a discussion on the idea
of authentic leadership in medical education. Dr. Irene W. Y.
Ma led a conversation on teaching point of care ultrasound
(POCUS) in Internal Medicine, as well as developing scholarship
to support its use. Dr. Daniel Brandt Vegas led a discussion about
how to teach clinical reasoning. Finally, given the sweeping
changes brought about by the implementation of Competency
Based Medical Education (CBME) across Canadian residency
training programs, we decided to dedicate a large segment of the
workshop to learn about the experience of a Gastroenterology
subspecialty group implementing CBME for maintenance of
competencies (MOC) using a peer mentorship program. Dr.
Ford Bursey led this segment.
The workshop was well attended, and the participation reflected
a level of enthusiasm and interest that suggests a potential for a
national collaboration and conversation in these different topics.
This article intends to reflect the experience of the workshop.
Leadership in Medical Education—Leslie Martin
Leadership is crucial for institutional success, particularly during
times of significant change. During the session, we explored areas
of medical education and clinical practice that are undergoing
rapid change, and will continue to shift in the coming years.
Leadership is crucial in all of these spheres in order to achieve
and maintain success.
Introducing authentic leadership
What kind of leaders should we seek to be during our career as
clinicians and educators? Whom do we need to emulate in order
to achieve success? Fortunately, it has been shown that there
remains “no clear profile of the ideal leader.
1
Rather, authentic
leadership emerges from ones personal story, experiences,
and understanding of who we are and how we can best serve
others.
1
Authentic leadership can incorporate other well
described positive forms of leadership, such as transformational,
Figure 1.
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charismatic, and servant, and is defined by core elements including
self-awareness, self-regulation, and positive perspective.
2
A
recent scoping review highlighted a general consensus that
authentic leadership should be promoted within health care;
however, there is a need for more research to understand the
role and value of authentic leadership in different populations,
contexts, and health care sectors.
3
How do we get there?
In the most recent CanMEDS framework, the decision was
made to change the role from “Manager” to “Leader” in order
to emphasize the importance of leadership as a core competency
for physicians, highlighting the integration of patient safety,
resource allocation, and health informatics as part of this role.
4
We are increasingly evaluating this “Leader” competency,
yet formal longitudinal leadership training is not universally
available within our medical education curricula. Given the
recognized importance of leadership development, there is an
increasing promotion of faculty development initiatives. These
initiatives have been found to improve the knowledge, skills, and
attitudes of participating physicians and led to the adoption of
new leadership roles and responsibilities.
5
Given the critical role of leadership in all spheres of medical
practice, we call for more research and systematic investment into
leadership development at the individual and organizational level.
Behind the Scenes: POCUS from an Educational
Scholarship Perspective—Irene W. Y. Ma
The utility of point-of-care ultrasound (POCUS) in assessing
medical patients at the bedside is increasingly being recognized.
In the United States, a number of Internal Medicine organizations
have issued position statements of support for its use, including
the American College of Physicians,
6
Society of Hospital
Medicine,
7
and the Alliance of Academic Internal Medicine.
8
While evidence is now beginning to emerge in its utility at the
bedside in improving diagnostic accuracy, such as the case
for the assessment of patients with dyspnea
9,10
and for the
determination of splenomegaly,
11,12
some critics argue against
its use, citing inconsistency in or absence of evidence for clear
educational benefits.
13,14
Incorporating POCUS into clinical medicine presents a
paradigm shift in the way that patient examinations are performed
at the bedside. Ability to directly visualize findings such as right
ventricular chamber collapse in the presence of pericardial
effusion and loculated pleural effusions in a septic patient provides
clinicians with valuable additional data points to guide and triage
the urgency of subsequent management strategies. But for each
sonographic finding, there exist false-positives and false-negatives,
some of which may be technique-dependent. In addition, clinical
context significantly impacts on the interpretations of any given
finding. Therefore, there is a critical need for physicians to be
trained properly in the use of this powerful tool.
Although its use is not intended to replace consultative
and comprehensive scans performed by diagnostic imaging
specialists, concerns regarding potential patient harm exist,
15
especially in the setting of insufficient understanding of the
scope of use, suboptimal training on its technique, interpretation
and clinical integration, and the absence of quality assurance
processes. Questions abound such as, “What is the evidence
for improving the accuracy of diagnosis?” “Can learners learn
the technique effectively?,” “Under what circumstances should
POCUS be used or not used?,” and “How should competency
be assessed?” As such, more than ever, there is an urgent and
pressing need for POCUS practitioners, clinician researchers,
medical educators, education researchers, and administrators
to work together to shape POCUS education, so that evidence
can be created and evaluated, and policies and processes can
be set in place to guide the responsible use of POCUS. This
task is daunting. As general internists, we are well versed in
clinical research and medical education scholarship. We are
therefore well-positioned to help collectively guide this POCUS
implementation effort, as evidenced by our collective work to
date.
16,17
Much more work needs to be done and the future for
POCUS is looking bright and echogenic. “In truth, whatever is
worth doing at all, is worth doing well; and nothing can be done
well without attention.”—Philip Stanhope, Letters to His Son on
the Art of Becoming a Man of the World and a Gentleman, 1752.
How to Teach Clinical Reasoning—Daniel Brandt
Vegas
Clinical reasoning and diagnostic skills have long been the focus
of educating Internal Medicine specialists. There have been many
strategies based on well-developed theories in cognitive psychology
that have been tried with varying experiential results. The dual
process theory is clearly the most widely accepted conceptual
framework used to understand and teach clinical reasoning.
18
Since
this theory proposes the combined implicit, intuitive, unconscious
thinking process (system I) with the explicit, rational, conscious
thinking process (system II), most efforts to improve clinicians
clinical reasoning have focused on the system II process.
19
Given
the conscious aspect of this process, it appears to be a reasonable
target for efforts to train and improve our thinking skills. However,
Monteiro et. al. recently made the argument that previous studies
have shown that efforts to improve the system II thinking process
have had minimal, if any, impact on diagnostic accuracy or
efficiency.
20,21
Given that other studies of clinical reasoning have
repeatedly shown that the best predictor for better diagnostic
accuracy is years of clinical practice and prior experience, they
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Proceed
to retain practice certification in their area of specialization. In 2015,
the RCPSC organized an international summit on competency-
based CPD, and since then there have been several efforts at
exploring the rationale for a change toward an updated model of
CPD based on the demonstration of clinical skills specific to each
specialty including peer mentorship and coaching.
23,24
Currently, the RCPSC requires members to demonstrate
participation in a set amount of hours of practice assessment
activities over a 5-year cycle. The clinical impact or educational
effect of these activities is not captured in this model. The proposed
shift is toward building on clinical skills beyond competence,
toward mastery through the review of clinicians performance
data as well as feedback provided by trusted colleagues and
mentors. The RCPSC website now includes items as a chart
audit tool that can be used by clinicians to review and reflect
on aspects of their practice.
As an example of this shift toward competency-based
CPD, the Canadian Association of Gastroenterology (CAG)
has developed a program that aims to develop and enable peer
feedback and support as part of CPD. The “Skills Enhancement
in Endoscopy” (SEE) initiative includes courses that promote the
move from competence toward excellence and mastery utilizing
coaching and provision of feedback to peers.
The CAG also promotes a program that assesses the clinical
quality of endoscopy services provided in over 200 hospitals in
Canada. The Canada-Global Rating Scale allows for the collection
of data from patients on the quality of their experience. This
allows reflection not only on the practice of individuals but also
of the entire care team. When collated and analyzed by individual
endoscopy centers, the team can reflect on and potentially
improve the quality of care of all allied health professionals that
make up the endoscopy services team.
We are moving toward competency-based CPD in Canada.
As there is likely to be increased attention on how clinicians
demonstrate continued or enhanced competence in their chosen
scope of practice, they will need to learn from each other on
how best to accomplish this.
Conclusion
Medical education is an area of growing interest and attention
for Internal Medicine given the important changes of the education
landscape across Canada. A recent workshop was delivered at the
2019 CSIM meeting in Halifax to provide an update and foster a
conversation on specific topics in this field, such as leadership in
education, teaching POCUS, teaching clinical reasoning skills,
and using a peer mentorship CBME framework to develop an
advanced CPD program. The goal is for this conversation to
continue over time and hopefully lead to national collaborations
in different areas within medical education.
propose that the way to improve clinicians’ diagnostic reasoning
is improving their knowledge of clinical medicine and increasing
their clinical experience.
Based on this, the following recommendations were made as
“best practices” for educators looking to teach clinical reasoning
in any context or at any level:
1.
Focus on the system I process of thinking. This means
dont focus on the actual process of thinking. Instead,
focus on ensuring that the clinician has a broad,
updated, and accurate knowledge of clinical medicine,
including pathophysiology, clinical presentation of
disease, basic epidemiology, and the basic operational
characteristics for diagnostic tests for clinical
conditions. Since acquiring this type of knowledge and
having it within our working memory takes a huge
effort and a very significant time commitment, having
the skills to quickly identify a knowledge gap and
efficiently address it is almost as important as having
the knowledge itself.
2.
The quality of the data being processed is as important
as the way the data is being processed. This means
that rather than focusing on teaching clinicians how to
think, its as important (and arguably less controversial)
to teach clinicians how to get high-quality and reliable
data. Ensuring clinicians have highly proficient
communication and history-taking skills as well as
advanced physical examination skills, including the use
of novel technology such as point of care ultrasound,
is a fundamental part of developing strong clinical
reasoning skills.
3.
The use of a systematic reflective practice, in which
a clinician reviews the intermediate and long-term
outcomes of the clinical decisions made can help
identify important knowledge gaps, as well as erroneous
concepts that need to be revisited. This strategy will
help focus and strengthen the process outlined in the
first point.
CBME and CPD—Ford Bursey
Medical education in Canada is in the process of adopting a
competencybased approach. The focus on feedback and coaching
this paradigm provides will help trainees achieve proficiency in
specific specialty-related and stage-appropriate clinical tasks. This
effort, however, has mostly focused on training programs, despite
the universally accepted idea of the physician as a lifelong learner.
The Royal College of Physicians and Surgeons of Canada
(RCPSC) and the College of Family Physicians of Canada, as well
as provincial regulatory colleges, have set the standard requiring
every physician in Canada to participate in CPD activities in order
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14. Feilchenfeld Z, Kuper A, Whitehead C. Stethoscope of the 21st century:
Dominant discourses of ultrasound in medical education. Med Educ.
2018;52:1271–87. http://dx.doi.org/10.1111/medu.13714
15.
Ebell M. Point-of-care ultrasonography: An effective tool when used
appropriately. Am Fam Physician. 2019;99:143.
16.
Ma IWY, Arishenkoff S, Wiseman J, et al. Internal medicine point-of-care
ultrasound curriculum: Consensus recommendations from the Canadian
Internal Medicine Ultrasound (CIMUS) group. J Gen Intern Med.
2017;32:1052–7. http://dx.doi.org/10.1007/s11606-017-4071-5
17. Ambasta A, Balan M, Mayette M, et al. Education indicators for internal
medicine point-of-are ultrasound: A consensus report from the Canadian
Internal Medicine Ultrasound (CIMUS) group. J Gen Intern Med. 2019:1–7.
http://dx.doi.org/10.1007/s11606-019-05124-1
18. Evans JS. Dual-processing accounts of reasoning, judgment, and social
cognition. Annu Rev Psychol. 2008;59:255–78. http://dx.doi.org/10.1146/
annurev.psych.59.103006.093629
19.
Norman G. Dual processing and diagnostic errors. Adv Health Sci
Educ Theory Pract. 2009;14(Suppl 1):3749. http://dx.doi.org/10.1007/
s10459-009-9179-x
20.
Norman G, Monteiro S, Sherbino J, Ilgen J, Schmidt H, Mamede S. The
causes of errors in clinical reasoning: Cognitive biases, knowledge deficits,
and dual process thinking. Acad Med. 2017;92:23–30. http://dx.doi
.org/10.1097/ACM.0000000000001421
21. Monteiro S, Sherbino J, Sibbald M, Norman G. Critical thinking, biases and
dual processing: The enduring myth of generalisable skills. Med Educ. 2020
Jan;54(1):66–73. http://dx.doi.org/10.1111/medu.13872
22.
Luthans F, Avolio BJ. Authentic leadership: A positive developmental
approach. In: Cameron KS, Dutton JE, Quinn RE, editors. Positive
organizational scholarship. San Francisco, CA: Barrett-Koehler; 2003.
p. 241–61.
23. Lockyer J, Bursey F, Richardson D, Frank J, Snell L, Campbell C.
Competency-based medical education and continuing professional
development: A conceptualization for change. Med Teach. 2017;39(6):
617–22. http://dx.doi.org/10.1080/0142159X.2017.1315064
24. Campbell C, Sisler J, on behalf of the FMEC CPD Steering Committee.
[Internet]. Available from: https://www.fmec-cpd.ca/wp-content/
uploads/2019/08/FMEC-CPD_Synthesized_EN_WEB.pdf
References
1. George B, Sims P, McLean AN, Mayer D. Discovering your authentic
leadership. Harv Business Rev. 2007;85(2):129.
2.
Avolio BJ, Gardner WL. Authentic leadership development: Getting to the
root of positive forms of leadership. Leadership Q. 2005;16(3):315–38. http://
dx.doi.org/10.1016/j.leaqua.2005.03.001
3.
Malila N, Lunkka N, Suhonen M. Authentic leadership in healthcare: A
scoping review. Leadership Health Serv (Bradford, England). 2018;31(1):
129–46. http://dx.doi.org/10.1108/LHS-02-2017-0007
4.
Frank JR, Snell L, Sherbino J. CanMEDS 2015 Physician competency
framework. Royal College of Physicians and Surgeons of Canada; 2015.
5.
Steinert Y, Naismith L, Mann K. Faculty development initiatives designed to
promote leadership in medical education. A BEME systematic review: BEME
Guide No. 19. Med Teach. 2012;34(6):483–503. http://dx.doi.org/10.3109/014
2159X.2012.680937
6. American College of Physicians. ACP statement in support of
point of care ultrasound for internists [Internet]. 2018. Available
from: https://www.acponline.org/meetings-courses/focused-topics/
point-of-care-ultrasound-pocus-for-internal-medicine
7.
Soni NJ, Schnobrich D, Matthews BK, et al. Point-of-care ultrasound for
hospitalists: A position statement of the Society of Hospital Medicine. J Hosp
Med. 2019;14:E1–6. http://dx.doi.org/10.12788/jhm.3287
8.
LoPresti CM, Jensen TP, Dversdal RK, Astiz DJ. Point of care ultrasound for
internal medicine residency training: A position statement from the alliance
of academic internal medicine. Am J Med. 2019. http://dx.doi.org/10.1016/
j.amjmed.2019.07.019
9. Filopei J, Siedenburg H, Rattner P, Fukaya E, Kory P. Impact of pocket ultra-
sound use by internal medicine house staff in the diagnosis of dyspnea. J
Hosp Med. 2014. http://dx.doi.org/10.1002/jhm.2219
10.
Perrone T, Maggi A, Sgarlata C, et al. Lung ultrasound in internal medicine:
A bedside help to increase accuracy in the diagnosis of dyspnea. Eur J Intern
Med. 2017;46:61–5. http://dx.doi.org/10.1016/j.ejim.2017.07.034
11.
Arishenkoff S, Eddy C, Roberts JM, et al. Accuracy of spleen measurement
by medical residents using hand-carried ultrasound. J Ultrasound Med.
2015;34:2203–7. http://dx.doi.org/10.7863/ultra.15.02022
12.
Cessford T, Meneilly GS, Arishenkoff S, et al. Comparing physical
examination with sonographic versions of the same examination techniques
for splenomegaly. J Ultrasound Med. 2018;37:1621–9. http://dx.doi
.org/10.1002/jum.14506
13. Feilchenfeld Z, Dornan T, Whitehead C, Kuper A. Ultrasound in
undergraduate medical education: A systematic and critical review. Med
Educ. 2017;51:366–78. http://dx.doi.org/10.1111/medu.13211
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