CBD Community Touchpoint - April 2018


CBD Community Touchpoint

Official CBD newsletter of the Royal College

Created to inform, support and connect. About

Message from the CEO

Royal College CEO Andrew Padmos

Dear Colleagues,

Competency-based medical education (CBME) is a worldwide movement that focuses on the learners, allowing them to guide their own educations, working at a pace that is right for them as individuals. Competence by Design (CBD) is the Royal College’s adaptation of CBME for residency training and specialty practice in Canada. De-emphasizing the time spent in training, CBD focuses on developing the implicit, discipline-specific competencies across all CanMEDS roles. This design is hoped to improve patient care by improving learning across the continuum, from residency to retirement.

Royal College staff and the postgraduate specialty medical education community across the country have been focused on the day-to-day hard work of transitioning specialty medical education to CBD for the past few years. Even though we are so focused, we continue to learn about CBME and assess our progress.

In this issue of CBD Community Touchpoint, we discuss assessment for learning, including assessing our progress and learning.

CBD offers a new approach to teaching and assessment with regular, direct observations to confirm residents are achieving Entrustable Professional Activities (EPAs) in real-life situations. A new Coaching Model will support the new teacher–learner relationship in CBD. This requires a change mindset for clinicians to act more like coaches than teachers.

In this issue’s Faces of CBD, Program Director Rob Anderson and PGY1 Andrew Shanmugarajah share their experiences with those observations in the Department of Anesthesia at the Northern Ontario School of Medicine.

The Royal College has adapted its MAINPORT ePortfolio to encourage residents to set their personal goals, to track their learning plans and to reflect and receive feedback on learning and assessment activities. The Resident ePortfolio is the tool that brings CBME theory into CBD reality.

While exams continue to be a part of CBD assessment, changes are coming there as well. Surgical Foundations will be the first exam to shift its timing to earlier in training. Read about it later in this issue.

The Royal College is also continuing to learn about CBME. We’re learning from the experiences of other countries that have implemented CBME. We’re learning from the experiences of the first two specialities to adopt CBD. We’re learning from the experiences of Queen’s University that implemented CBME across all of its disciplines. Like CBD, we will be assessing our learning. We hope you will be among the observers from across the country who will provide us feedback, so we can learn and improve as more disciplines transition to CBD.

Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer


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Understanding the CBD Coaching Model

The teacher–learner relationship: Understanding the CBD Coaching Model

The term coach conjures up images of the whistle-toting leader of a sports team who corrects and encourages athletes as they work to improve their performance. Not so far removed from this scenario are residents, striving to learn from teachers and willing to put in extra hours to become the best specialist they can be.

But what makes a good leader to these residents in today’s challenging environment? And what are the best practices for building the relationship between the clinical teacher and the resident learner?

Understanding the CBD Coaching Model

The Royal College has worked with leading medical educators to develop the CBD Coaching Model and complementary suite of resources to help guide and support teaching and learning under CBD.

In CBD, coaching is both a teaching method and an element of workplace-based assessment, which is formative in nature. The CBD Coaching Model includes two coaching components: Coaching in the Moment and Coaching Over Time.

Coaching in the Moment requires clinicians to establish rapport and set expectations with their residents, observe the residents doing their daily work, provide coaching feedback and document the encounter. Frequent observation is a key ingredient.

Coaching Over Time needs a longitudinal relationship between a clinical faculty member and a resident. It needs regularly scheduled, face-to-face discussions about the resident’s progression toward competence, more than a single clinical experience. Any recognized performance patterns are used to plan learning opportunities. For this educational partnership to work well, residents must feel confident that the clinician has the resident’s best learning interests in mind.

Both components use coaching to guide learners through a growth process that leads to improved performance. Coaches provide feedback about what they noticed during an observation and, most importantly, what specific, actionable suggestions they have for the resident to improve. In other words, coaching feedback helps residents understand what they need to change to progress to the next level of competency.

Learn more about the CBD Coaching Model and resources, or watch the video.



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The faces of CBD

Early insights: regular, direct observations

Interview with
Rob Anderson, MD, FRCPC

Anesthesiology Program Director
Associate Professor
Northern Ontario School of Medicine
Clinician Educator Workplace Based Assessment Committee,
Royal College

Andrew Shanmugarajah, MD
PGY1 Anesthesiology
Northern Ontario School of Medicine

With the first two disciplines launching their Competence by Design (CBD) programs last July and six more ready to launch this coming July, we offer a glimpse into one of the new aspects of the hybrid competency-based medical education system — regular, redirect observations.

For this issue of CBD Community Touchpoint, we wanted to look at both sides of this CBD component. We talked with Residency Program Director Rob Anderson and PGY1 resident Andrew Shanmugarajah about their experiences with regular, direct observations in the Department of Anesthesia at the Northern Ontario School of Medicine. Here is what they had to say.

What do you see as the real advantage of regular, direct observations in CBD?

Dr. Anderson:

Increasing the number and refining the structure of direct observations combined with coaching feedback in the CBD paradigm leads to an enhanced learning trajectory for all learners. It seemed unfair to me that residents who were struggling had to have remediation, often meaning increased and focussed direct observation and feedback. If it improves the learning of those who are struggling, why not give this advantage to all learners, regardless of where they are on the spectrum? Today’s residents yearn for more frequent, specific and actionable feedback than ever before. CBD can respond to that need.

Dr. Shanmugarajah:

Regular, direct observations have allowed each bit of feedback I have received to be specific and actionable. Instead of a global assessment of my performance for a given day, week, or month, I have received focused direction daily. Being able to follow my own progress and being asked to reflect on my learning needs has also given me some ownership and control over my clinical learning.

Describe your role in CBD observations.

Dr. Anderson:

As a program director in the early days of CBD, my role has been to help create, structure and revise the observations; provide faculty development on accessing the forms and giving high quality feedback; provide resident development on “gently teaching faculty” how to play in a CBD world; and guide the use of the observations. A key aspect of CBD observations is the “not yet competent” ones and providing coaching feedback. This is vital to learner growth. Residents should want to get coaching feedback before becoming competent as much as to document competence. Competence committees need to look favourably on the assessment for learning. This is a mindset change for all and an important part of my job is supporting that change.

Dr. Shanmugarajah:

As a resident, my role is to determine what observations and (Entrustable Professional Activities) EPAs I need and look at my academic schedule to see how I may achieve them. The onus is also on me to be proactive each day and tell my preceptors which EPAs I would like to be assessed on. I am also expected to develop a learning plan, shared with the competency committee, to ensure that my priorities are appropriate and that I am continuing to maximize the results of my training.

What challenges did you encounter?

Dr. Anderson:

Working with outside groups, such as the off-service rotations that are just learning about CBD, can be a challenge, but always achievable. There are certainly glitches along the way. Changing technology, evolving definitions and assessment strategies, creating a competence committee and not an evaluation committee, defining the role of simulation and determining finances are all hurdles that we are struggling with. Having a clear vision and the supportive team, locally and nationally, has made them just problems to be solved, not impassible barriers.

Dr. Shanmugarajah:

One of our biggest ongoing challenges is collecting observations while on off-service rotations. Certain EPAs are mapped to those rotations, but the transition has been difficult, especially in rotations where you are not interacting regularly with a staff physician.

Did you encounter any surprises?

Dr. Anderson:

For me, the biggest surprise is the robust and thoughtful conversations at the competence committee. We have had an evaluation committee for a long time, looking at flagged evaluations and supporting the struggling residents. Our competence committee does an in-depth review of each resident. The collective wisdom and experience have been keys to providing support and feedback to all the residents. I don’t worry that someone may be falling behind or struggling, and we didn’t catch them in time to help them. It has been a very positive experience despite the added workload. It feels like valuable and important work!

Dr. Shanmugarajah:

I’ve been surprised by how much some preceptors have bought into the CBD assessment strategies, actively thinking about EPAs I can accomplish or filling out assessments on observed skills without my asking them. Their continued efforts have made the transition a lot easier than I expected it to be when I started my residency.

What is important to keep in mind about CBD observations?

Dr. Anderson:

The single most important thing is that the intent of observations is to facilitate learning and development, not just to document it. If we are afraid of giving coaching feedback or marking below independent, if the competence committee looks at below competent observations as a concern, if residents don’t ask for observations before they feel they can do it independently … then we risk falling back to just documenting competence and flagging fails. Then we missed adding the value associated with this change.

Dr. Shanmugarajah:

The observations are meant to reflect residents’ growth. I will still sometimes lose sight of this because it can feel uncomfortable being assessed when you are not yet competent. However, waiting until I feel competent to ask for an assessment defeats the purpose of CBD and wastes opportunities to enhance my growth earlier in my training.

If you could tell physicians in another medical specialty one thing about preparing for CBD observations, what would that be?

Dr. Anderson:

I would say the same thing I was told by one of the CBME leads in the Ortho program at U of T. Just get started. Pick two or three aspects to observe that seem easiest and adapt assessments for them that have already been invented. Engage a few leads who will do a great job and start doing some observations. Don’t get too set in your ways, as things will change a lot along the path to the new norm. You can learn a lot from just doing a few, and you can apply that to the rest of your journey.

Dr. Shanmugarajah:

From my experience, it requires significant buy-in from learners and educators. It is a new style of assessment, requiring a new mindset from both parties. Learners must become comfortable being assessed before they are competent, and assessors must feel comfortable assessing someone as temporarily incompetent. It provides opportunities for teaching earlier and reveals a resident’s growth over time. The process is also enhanced if learners and educators are proactive about knowing what EPAs exist and recognizing opportunities for assessments as they arise.


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Pocket full of Change

Rhonda St. Croix

The keys to lead successful change: Taking a coaching and feedback approach

Despite the most resonant vision, sustainable and meaningful change begins when people choose new behaviours. CBD requires change at many levels — system, organizational, discipline, program, cultural, process, relationships and roles.

In the first instalment of this column, I talked about the tendency to follow top-down, plan-driven approaches to change. While these are necessary, they are not equipped to navigate complexity. Success with complex change requires coaching and feedback-driven approaches. We will achieve more if we take a coaching approach to close the gap between our current reality and the desired outcome, change ourselves first and seek honest feedback from those affected by the change.

So in this edition, I explore the role of coaching and feedback in CBD and in change.

The father of quality, Dr. Edward Deming declared, “There can be no organizational transformation without personal transformation.” Leaders cannot bring about real organizational change without going through personal change. We create change in our day-to-day interactions by shifting our individual thinking and our actions. The shift to a better future does not have a chance of happening unless we are willing to change ourselves first – the aim of coaching.

A key principle of leading change is that the quality of the change process needs to match the essence of the change. For example, if the change is about creating a more participative and inclusive culture, then we need to lead and design the change in a participative and inclusive way. Because CBD is about creating a culture of coaching and feedback, we need to take a coaching and feedback approach.

So how can the process of coaching and feedback help us go about changing ourselves and our behaviour, so we can succeed with implementing CBD? A few strategies are useful here.

Recognize the dip.

As soon as we articulate a vision for a new future, we create change and possibly tension, discomfort and conflict. Whenever we receive feedback from a different perspective (whether it’s one-on-one or from a room full of stakeholders), a sense of loss is natural, which can rock our self-image. We can’t let this dip erode our commitment and willingness to change. We need to wade into the discomfort and vulnerability. As Brene Brown says, “Vulnerability is the birthplace of innovation, creativity and change.” Hopefully this takes place in an environment that feels safe and does not take us too far outside our comfort zone.

There is a sweet spot between challenge and support. Too much feedback too often can be overwhelming and can break us down. Too little feedback and we can be too much in our comfort zone and stuck in the status quo.

Cultivate a growth mindset with receptivity to feedback.

Meaningful behaviour change can be difficult, and we need feedback to see ourselves more clearly. For example, many communities are trying to slow traffic by providing feedback using radar speed displays. These work by providing a feedback loop — driver speed (action), see the display (information) and reduce speed (response). Action–information–response feedback loops are seldom that straightforward.

Regardless of the behaviour change challenge, we need to be better able to let the feedback in. We can do this by assuming the person providing the feedback has a positive intent to help us learn and grow. This will help us let go of being defensive. We need to be open, curious and ask questions to understand what others can see that we can’t. This is really the move from defending against what’s wrong with the feedback and the giver, to suspend what you already know, and to lean in and invite others to expand their thinking. This is the opening where we are able to identify some insights and possible options to close the gap between current state and desired state. Don’t be afraid of the gap.

Take a coaching approach — action based on small steps and experiment.

After we deal with the discomfort of new perspectives, interpret what’s right and true and identify some options, it’s time to take action. As Marshall Ganz has said, “If we don’t begin to act, we can’t begin to learn.”

When it comes to behaviour change, less is more, so we can identify one new behaviour to start or stop. This is best done with an experimental approach. Try the new behaviour to test and learn. Some experiments will not produce intended results and others will lead to some positive results. Identify what action you will take and how you will assess the results. Commitment to new behaviours takes time to develop and is derived from experience gained and lessons learned.

Implementing complex change in medical education takes time and requires adaptation, small wins and a tolerance for messiness. As complexity guru Dave Snowden says, “We need to do small things in the present rather than promise large things in the future.”

For additional reading:


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answers to Resident ePortfolio questions

Answers to your Resident ePortfolio questions

In this issue of CBD Community Touchpoint, we answer some of the questions the Royal College has received about its Resident ePortfolio.

Resident ePortfolio is a variation of the Royal College’s existing MAINPORT ePortfolio, which Fellows and in-practice physicians use to track their participation in the Maintenance of Certification (MOC) program. The Resident ePortfolio is a free and valuable learning tool to support teachers and residents with competency-based assessment by

  • providing an electronic capture of observations
  • containing up-to-date Royal College educational standards and program learning plans
  • enabling competence committees to assess learners’ progress
  • facilitating learner and observer interactions
  • producing analytics and reports for monitoring and benchmarking
  • archiving a physician’s learning data in a single secure location

Here is what you’ve asked us.

Is the use of the Royal College Resident ePortfolio mandatory?

The Royal College knows that many of our university partners have systems in place to record, assess and access resident data, so the Royal College Resident ePortfolio will not be mandatory for any university or program. However, the use of an electronic portfolio is needed to enable workplace-based assessment.

Would I be able to see how ePortfolio works? Is there a trial version?

The CBME leads and super users at schools that have signed a University User License Agreement have been provided with access to the ePortfolio Test environment. This environment can be used to demonstrate system functionality and support faculty development within their school. There are a limited number of accounts, so schools are encouraged to limit usage to specific individuals to limit overlaps in use.

When will my specialty have access to ePortfolio?

With Anesthesiology and Otolaryngology — Head and Neck Surgery’s CBD launch last July, the system is already being used at schools that have registered to use the platform.

Emergency Medicine, Forensic Pathology, Medical Oncology, Nephrology, Surgical Foundations and Urology are ready for this coming July’s CBD launch. Users for this cohort are already being registered.

For specialities launching CBD in July 2019 and beyond, access will be provided before launch to allow system training and awareness, depending on how quickly the specialty finalizes its English and French CBD document suite. Once Resident ePortfolio is loaded with their discipline-specific EPAs and milestones, registration for access to the system will begin. See the CBD Launch Schedule for your specialty’s targeted launch date.

Is there any possibility that my program could get access early to the ePortfolio, so our new residents who will be starting in July 2018 can learn how to use the system?

Yes, registration for the 2018 disciplines is ongoing. You can pilot this with your new residents before July. Please keep in mind that this is the live system. Recorded observations cannot be deleted and will remain in the system.

How do we get started transitioning from our existing platform to ePortfolio? Do you need anything specifically from us?

After your university has signed up for ePortfolio and your specialty’s suite of documents is uploaded into the system, all the Royal College needs is the list of users from your school and what roles they will need in the system. Please email that information to eportfolio@royalcollege.ca. For most of the users, we only need their first and last names and email addresses. For residents, we also need their Medical Identification Number for Canada (MINC) or their date of birth, the university where they obtained their medical degree and the year they obtained it. After your users are registered, we will send them a confirmation email. No other setup is required.

How do I get a copy of the observation templates and Entrustable Professional Activities (EPA) grids to use as examples with the various divisions I will be working with?

The observation templates are available by completing our online request form. After you agree to the terms and conditions, we will immediately send you an email with a link to access the observation templates and EPA guides.

Who can register me, so I can review an ePortfolio submission?

If you are launching CBD this year, program administrators will send the Royal College registrations for your program or discipline via eportfolio@royalcollege.ca. If you do not launch this year, please contact your program administrator for information.

Where can I find training materials? The webinar mentions new and ongoing information that will be available.

If you are a registered ePortfolio user, login to the system, click on the Need Help link in the top right. That’s where you can find training modules for each role built into the system.

Can I use my mobile device?

Resident ePortfolio is built with a responsive design, so it will adjust the display appropriately for the screen size. However, if you wish to use the ePortfolio application offline, you will need to download the iOS app from the Apple Store. This app is available in English and French.

Will there be an ePortfolio app on BlackBerry World or on Amazon?

At this time, we are tracking requests for apps on other stores (for example, Google Play and Amazon) and will decide whether to release the app on different platforms.

How is the ePortfolio data stored and who can access it?

The ePortfolio data is stored in Canadian data centres. Access to data is limited to what is needed to support candidates through registration, credentialing, exam registration and certification. The Royal College has no other access to the data. Additional information about data residency and privacy can be found in the End-User License Agreement (EULA). You can read the Royal College’s privacy practices at www.royalcollege.ca/rcsite/about/privacy-e.

If you have Resident ePortfolio-related questions you would like to ask, email them to eportfolio@royalcollege.ca.


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The pioneers of earlier CBD exams

The pioneers of earlier CBD exams

Surgical Foundations may not be the first to transition to Competence by Design (CBD), but it is the first to have earlier exams.

After two disciplines launched in July 2017, Surgical Foundations is one of six programs to launch July 2018. Emergency Medicine, Forensic Pathology, Medical Oncology, Nephrology and Urology are the others. With Surgical Foundations being a two-year program, it is the first to move up its exam from the spring to the fall.

Specialty committees determine the timing of exams based on the needs of their disciplines. For most disciplines, the CBD format means exams will shift to be earlier in training, likely at the end of the Core of Discipline stage. This will allow residents to hone their skills and prepare for independent practice in their final year, instead of being lost in textbooks studying for their exams.

More than 450 Surgical Foundations residents will start their surgical specialty training this coming July. By Aug. 31, they will need to apply for the new, earlier fall 2019 CBD Surgical Foundations exam. That year will be unique in that the Surgical Foundations exam will be offered twice. The 450 residents who started their surgical training in July 2017 need to apply for the last traditional spring 2019 Surgical Foundations exam before April 30, 2018.

The Surgical Foundations program is the initial period of postgraduate training where residents learn the fundamental skills of surgery. Nine surgical specialties require this program be completed, including

  • Cardiac Surgery,
  • General Surgery,
  • Neurosurgery,
  • Obstetrics and Gynecology,
  • Otolaryngology — Head and Neck Surgery,
  • Orthopedic Surgery,
  • Plastic Surgery,
  • Urology and
  • Vascular Surgery.

Residents complete the Transition to Discipline and Foundations of Discipline stages of Surgical Foundations and their surgical specialty training at the same time.

The Surgical Foundations Competence Committees and program directors monitor residents’ progress through the Surgical Foundations Entrustable Professional Activities (EPAs) and recommend promotion to the next stage of the competence continuum. At the same time, the primary surgical specialty competence committees and program directors monitor progress on the EPAs for their specialties and recommend promotion to the next stage.

Residents must complete all Surgical Foundations EPAs before they can be promoted to the Core of Discipline stage of training in their surgical specialty. Residents do not need to pass the Surgical Foundations exam to enter the Core of Discipline stage of training, but they must pass it to be eligible for the surgical specialty exam.

The Royal College continues to work closely with program directors, exam board chairs and specialty committee chairs in Surgical Foundations and the nine surgical specialties to ensure a smooth transition to CBD and the new exam timing.


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Early, real-life observations of CBD

As part of the evaluation of CBD, the Royal College brought together on-the-ground partners to talk directly with Royal College Council to get feedback on what lessons they have learned and where CBD needs to improve. Council is the Royal College’s governing body.

During the Feb. 23 Council meeting, Royal College Past President Dr. Kevin Imrie moderated a panel discussion with competency-based medical education (CBME) lead and residents from across the country. They included:

  • Sohaib Al-Asaaed, CBME Lead at Memorial University and Assistant Professor of Oncology
  • Janice Chisholm, CBME Lead and former Anesthesia Residency Program Director at Dalhousie and an Associate Professor of Anesthesiology at the QEII Sciences Centre
  • Robyn Doucet, the new Anesthesiology Program Director at Dalhousie
  • Eric Guimond, Anesthesiology resident at Université de Sherbrook
  • Dr. Anna Oswald, CBME Lead at the University of Alberta and an Associate Professor in the Division of Rheumatology in the Faculty of Medicine and Dentistry
  • Gurtej Sandhu, Internal Medicine resident at the University of Alberta

The group discussed what worked well and what didn’t work well for their respective programs, as well as which resources they felt were most useful to them when preparing for the transition to CBD. They shared what surprises they encountered along the way and what advice they would have for program directors, residents, CBME leads and department heads in other disciplines preparing to implement CBD, as well as for the Royal College preparing to support the launch of future cohorts.

Royal College President Dr. Francoise Chagnon expressed Council’s appreciation for receiving input from those implementing CBD, saying it was not about communications but establishing relationships. The Royal College will learn from the observations the panel shared via Skype and improve CBD as the specialty medical education community launches more disciplines.


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The CBD Community Touchpoint e-newsletter informs the medical community about issues, developments and activities that are related to CBD implementation across Canada.