4. Basic Concepts in Heath Care Training
“a set or series of interconnected or interdependent parts or
entities that act together in a common purpose or produce results
impossible by action of one alone”.
5. Old Training Model
Process
Structure
Outcome
Prevent the
Six Ds:
Death
Disease
Disability
Discomfort
Dissatisfaction
Destitution
(cost)
Care
Process
Anatomy
•Focus on
Knowledge &
Clinical Skills
•General &
Specialty
Rotation
7. Old Style Rota:
General &
Subspecialty
Traditional
Training
Programs
…………………
………Who
needs them?
New Modules/Rotations:
EBM Rotation: EBMers
Research & Audit: Researchers/Quality
Medical Technology: Innovators
Medical Bioethics: Ethical Workforce
Community Health: Economy/Prevention
Medical Education: Teachers/Trainers
Others!
9. 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
10. 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 Round
2. Sitting Ward Rounds
3. Short Case Discussions
4. Long Case Presentations
5. Actual Patient & Simulation –Technical
Skill Lab Training
6. 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 their
practice
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
11. 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 basis
Self-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 &
Quizzes
Personal:
Medical Knowledge Assessment
Program (MKSAP)
Cecil's MCQs
's MCQs
Multi-source Feedback
Short Answer Questions
MCQ
Scholar
12. Scholar
Sub-competency Recommended Activity Recommended Method of Delivery Recommended 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
13. 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
14. Sub-competency Recommended Activity Recommended Method of
Delivery
Recommended Assessment
Tool
Clinical Care Collaboration Leadership skills
Skills
Multidisciplinary/
Interdepartmental Care
Dynamics
Resolution of Interpersonal
Conflicts
Discharge Planning
Lectures
Small groups (PBL)
Role modeling
Daily progress
note assessment.
Review of dictation
summary
Written tests (short-answer
questions, essays)
In-training evaluation
reports (ITERs)
Objective structured
clinical examinations
(OSCEs)
Simulation
Multi-source feedbackCommunity Patients’ Friends Societies
& Support Groups
Government Bodies
Collaboration
Lectures
Small groups
International Research Collaboration
Quality of Care
Collaboration
Lectures
Small groups
Collaborator
15. 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 ObservationEffective 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
LEADER/MANAGER
16. 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
17. 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
18. Current and Future Plans
CanMEDS-skilled Faculty.
Outcome:
CanMEDS Cttee restructuring PLUS a Train-the-Trainers
program:
Vertical TTT Program: inclusive of Senior Faculty and
Residents
Horizontal TTT Program: Compulsory longitudinal
program
19. 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.
20. 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).
21. 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.
22. 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
23. 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
27. Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement)
1990; 65: S63-S7.
Knows
Shows how
Knows how
Does
Professionalauthenticity
Cognition
Behaviour
facts and concepts
problem solving
skills labs
practice
TRAINING OF COMPETENCIES: MILLER
29. Session Knowledge Understanding Skill/Practice Extras for the Skill Reflection Assessment
Documentation:
Follow-up Notes
Sign-Out/Handing Over
notes
Lecture: SOAP
Sign-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
30. 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
31. Session Knowledge Understanding Skill/Practice Extras for the Skill Reflection Assessment
Career Management Skills Lecture:
Job
Searching
Writing
curriculum
vitae, personal
statements
and covering
letters
Interview
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 Scenarios
Audit 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 Leader Role: See-One-Session SOS
33. 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.
5. Competency-enhancing Cognitive Aids like the 5S Cognitive
Aid, Communication Cognitive Aids etc.
34. Restructuring the Process of Training and Assessment:
6. End-of-Rotation Competency Appraisal Form (ERCA).
7. Online Logbook
8. Using CanMEDS competencies in the Journal Club.
9. Dedicated Morning Meeting on the CanMEDS Competencies; 1st Monday of
each Month.
10. Wiggio CanMEDS Resource webpage.
35. 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
Leader/Manager when dealing with system/process improvement
Communicator when breaking bad news etc
Professionalism when discussing ethical issues etc
36.
37. The Competency Structured Presentation (CSP)
Classically and for educational purposes both undergraduates
and postgraduates present clinical topics in a narrative or
case-based style.
In both of these, classic headings that are used include
definitions, etiology, epidemiology, clinical presentation,
differential diagnosis, investigations, therapy and prognosis
etc.
38. The Competency Structured Presentation (CSP)
These formats of presentation do not explicitly
emphasize the new domains of knowledge or skills
necessary for both quality of care as outlined above or
empower the trainees with all the competencies outlined
by CanMeds or similar bodies for a comprehensive
outcome-based training and patient care.
39. The Competency Structured Presentation (CSP)
Topic heading are now deliberately portrayed under
competency headings.
Presumably, this conceptual framework or map would assist in
realizing a more competency-directed clinical training and
decision making and in drafting a comprehensive, high-
quality management plan for every patient.
Practical patient-centered care actions and interventions may
thus be incorporated in the clinical decision process.
40. 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
training
and decision-making
process, and in drafting
a comprehensive,
high-quality management
plan for every patient.
41. Competency
Structured
Topic
Presentation
Bronchial Asthma
Advocate 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
Leader 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
42. 3. Competency
Structured
Morning
Meeting
Hassan IS, Kuriry H, Al Ansari L, Al-Khathami A, Al-Qahtani M, Al-Anazi T, Faroqui, M, Al-Jahdali H.
Competency-Structured Case Discussion in the Morning Meeting: Enhancing CanMeds Integration in Daily
Practice. Adv Med Educ Pract. 2015;20;6:353-8.
43. The CanMeds Ward Round!
• 12 Yr old, was admitted with an exacerbation of Bronchial Asthma- a new
diagnosis.
• CanMed Ward Round: Resident Training
–As a medical expert: were the H & P up to CanMeds standard-structured,
comprehensive, relevant etc.
–As a Communicator: Presentation skill? Body-Language? How did he/she
convey the news to the family? Empathy & support?
–As a Collaborator: Were the necessary referrals appropriate and
professionally arranged?
44. • 12 Yr old, was admitted with an exacerbation of Bronchial Asthma- a new diagnosis.
• CanMed Ward Round: Resident Training
– As a Leader: 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-steroid therapy etc
Case Scenario….The CanMeds Way!
45. 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.
47. 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
Cholangio-
carcinoma
Communicator
Breaking bad news
and discussing
putting the patient
no code with the
family
Using SPIKES mnemonic for
breaking bad news
Providing written material
on what no-code means
Involving Religious affairs
department
Policy and Procedure for
NO Code patients with
both Physician and
Family educational
inputs, written material
etc
48. 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
Elderly patient
with dementia,
Parkinsonism,
and bed-bound.
Admitted with
aspiration
pneumonia.
Collaborator
Patient 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
disease
Preventative interventions
including vaccination
Pre-marital counseling and
husband screening for genetic
Hospital wide genetic
disease patient and family
education support team,
procedure and policy
49. 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
Ward-round
Time
Leader
Ward round taking too
long
Time management skills
Use 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
Scholar
How to manage such
patients?
Literature searching for best
available evidence for
dealing with this problem.
Patient is
unhappy with
the provided
medical care.
Professiona
l
Physician-patient-
family conflict with its
negative impact on
patient care
MRP-Family conference
Involving trustworthy
Colleagues
Involving patient relations
department
Policy-procedure for
conflict resolution
50. Using CanMEDS headings in Journal Club:
Competencies Used
Scholar
Communicator (PPT Presentation)
Professional
Leader
51. Competency Guide: Medical Expert
1. Hypothesis-Driven History Taking and Physical Examination.
2. Detailed Problem-List for comprehensive care inputs
3. Use of Calculators and Scoring Tools for decision-making
e.g. BMI Calculator, CURB-65, Well’s Score for PE risk, Creatinine
Clearance, NIH Stroke Score, Bode Score for COPD survival
prediction, Ranson’s Score etc. UpToDate has a huge collection.
52. Competency Guide: Medical Expert
4. Patient- and Family Centered management decisions
e.g. use of decision-aids.
5. Using the BESD and 5S for comprehensive immediate
diagnostic and therapeutic input.
6. Avoiding Cognitive Biases Skills: DD Scheme, Rules
of Thumb, Ruling out worst scenario, ROWS, Red Flags
etc.
7. Procedural skills-: CanMEDS Technical Skills
Round/Simulation Lab: e.g. Lumbar Puncture, Ascitic Tap
etc.
53. Competency Guide: Communicator
Documentation: H&P, SOAP, SBAR/I-PASS
Handover, Discharge Summary, Medical Report
etc.
Consultation Referrals-using SBAR/I-PASS
Counseling Skills, Dealing with angry clients,
Breaking Bad News, Disclosure of Error
Motivational and Therapeutic Communication
Presentations in meetings, committees,
conferences etc.
57. CBME in Summary
Getting theory into practice
Is a Complex but Achievable
Task
Collective Effort
Organizational and Individual
Responsibilities
Patient Right