CBD Community Touchpoint - September 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,

Autumn officially starts on Sept. 22 and with it carries an air of possibilities. In the context of CBD, education and training, we look forward to new possibilities for learning and improvement.

This July 1, six disciplines joined Anesthesiology and Otolaryngology – Head and Neck Surgery in implementing CBD for new trainees. It wasn’t long ago that their CBD start dates seemed far in the future. Months of work have flown by and the new academic year is now upon us with CBD a reality for hundreds of residents.

In this issue, we take a look back over the past year, recognizing how feedback from across medical education has helped shape CBD as it moves forward. Input from groups such as the program directors for Anesthesiology and Otolaryngology – Head and Neck Surgery, highlight the benefits and challenges faced so far, while also guiding the refinement of the CBD model moving forward.

In our ever-popular Faces of CBD profile, Dr. James Watterson, vice chair of education in the Department of Surgery at the University of Ottawa, shares insight on how he believes CBD will benefit residents, in particular when it comes to the benefits of self-directed learning.

I truly believe that at the core of CBD’s success, lies in the ability to collect and incorporate feedback from partners and stakeholders from across medical education. We close off this issue by taking a closer look at the Fédération des médecins résidents du Québec (FMRQ) comprehensive study of CBD implementation.

I hope you find this issue helpful for whatever stage of CBD implementation you’re working in, and that you will share feedback of your progress so far, so that we can continue learning and improving the overall CBD system.


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


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Understanding the CBD Coaching Model

Collaborative, continuous improvement: CBD one year post-launch

Since starting to work on the Competence by Design (CBD) initiative in 2013, the Royal College and its postgraduate medical education partners have envisioned the approach to CBD implementation as an iterative process. The phased approach, launching a few disciplines each year, allows stakeholders to review assumptions and test components, processes and tools to refining implementation, end-to-end, in a real-world environment. Fundamental to CBD’s shared success is co-creation and mutual learning among all stakeholders.

Learning from those living CBD

The collection of feedback through the Implementation Pulse Check Survey is one of the keys ways we are ensuring we are learning from those on the ground. Last December program directors from Anesthesiology and Otolaryngology —Head and Neck Surgery shared invaluable feedback with the Royal College. Here are the highlights of what we learned.

Cost and resources identified as key issues

The cost and resource demands of implementing CBD on the ground were key themes from respondents. To help address this, the multi-stakeholder Resource Framework Working Group (RFWG) will lead a review of the local variations in costs and resource implications of CBD. With coordination support provided by the Royal College, the RFWG is co-chaired by Dwayne Martins, Chair of the Association of Faculties of Medicine of Canada (AFMC) Committee of Senior Administrators, and Jason Frank, Director of Specialty Education, Strategies and Standards at the Royal College.

The working group plans to survey and interview all 17 faculties of medicine and all program directors of 2017, 2018 and 2019 launch disciplines. The group expects to share a preliminary report with postgraduate medical education partners and other stakeholders by the end of September and a complete report in fall 2019.

The information gathered in this study will help all stakeholders understand the spectrum of resource investments that have been made by individual faculties, with a goal of helping them plan future discipline launches.

Evaluating long term success

A project team, including Royal College staff and lead consultant Elaine Van Melle, are working on a collaborative program evaluation of CBD with a variety of stakeholders. CBD has three goals that the Royal College will evaluate:

  • foster successful implementation of CBD,
  • understand the influence of local contexts (how each medical school and specialty is unique), and
  • contribute to the growing research evidence on competency-based medical education (CBME), including patient-focused outcomes and unintended outcomes.

To find out more about how CBD will be evaluated, watch the Program Evaluation webinar recording.

If you have feedback, ideas and lessons learned that you would like to share, please email them to cbd@royalcollege.ca.


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Understanding the CBD Coaching Model

Lessons from the field: PD survey results

In December, the Royal College surveyed Anesthesiology and Otolaryngology – Head and Neck Surgery program directors. This survey asked them about their CBD implementation status, including the benefits and challenges they have faced so far. The total response rate was 63.3 per cent, and follow up interviews were conducted in February to delve deeper into CBD experiences.

“There are volumes of research papers that support competency-based medical education [CBME], so we know that CBD is built on a strong foundation. But beyond the theoretical, the day-to-day practical application needs to be tested in the real world,” said Ken Harris, Deputy CEO and Executive Director of Specialty Education. “Getting feedback from the lived experiences of program directors is invaluable for the Royal College and all stakeholders to learn from and improve this major shift in specialty medical education in Canada.”

Role-specific Resources

A common piece of feedback was that CBD information is often too vague and not always oriented to a specific audience. It was suggested that more concrete guidance should be offered that is targeted to specific audiences. Program directors also asked for advice on how to work with residents who are experiencing academic or professional issues.

“To help bring CBD from the theoretical to the practical, the Royal College is developing and starting to offer role-specific Resident ePortfolio training webinars, mock competence committee cases for deliberation practice, videos for each aspect of competence committees and webinars addressing issues as we become aware of them,” said Jason Frank, Director of Specialty Education, Strategies and Standards.

Engage school leadership

Some program directors indicated that their school’s leadership, such as the deans, vice deans, postgraduate medical education office and department chairs, could have been better supported in preparing for implementation with regards to resource implications. “The Royal College is committed to continuing to engage our diverse stakeholders in the medical education community to work and learn together to make the necessary and timely adjustments to CBD implementation so we can achieve our greater goal of enhanced patient care,” Harris said.

Royal College Resident ePortfolio enhancements

As part of the survey, some respondents emphasized the need for enhancements to ePortfolio, including usability and features for showing resident progression. Based on this feedback, the Royal College has taken key improvement steps, including EPAs being loaded further in advance.

“With the Resident ePortfolio up and running with processes in place, Royal College staff were able to get the entrustable professional activities (EPAs) and users loaded for the 2018 disciplines earlier than was possible in 2017,” said Jane Fulford, Executive Director of Information Management Technology Services and Chief Information Officer. “For the 2019 launch of more disciplines, staff are aiming to have EPAs uploaded even earlier, based on speciality committees finalizing their documents. As well, a new system will be rolled out to allow program administrators to manage their users, including uploading large lists of new faculty and maintain user roles without needing to contact the Royal College.”

The importance of being two steps ahead

A few respondents emphasized the importance of proactive planning. For instance, it was noted that important policies, such as the resident transfer policy, should have been developed and agreed upon before launching any disciplines.

“As the first programs launch in the new national standard of CBD, it is expected that there would need to be changes along the way. One of the reasons why disciplines are being launched a few at a time is so we can learn from the experiences of the early adapters and improve the processes and infrastructure to support future iterations,” Frank said. “The Royal College will continue working with medical schools on all areas of implementation.”

Advice from PDs for PDs

We asked participants to offer advice to future CBD program directors based on what they have learned so far. Here are the common themes!

  • Embrace a gradual approach to implementation
  • Be aware of the amount of work and required resources
  • Engage residents: Encourage a growth mindset and emphasize the assessment for learning component
  • Engage faculty: Provide in-depth training to a few faculty members to help coach others and move CBD forward

Let us know how your program or school is addressing these concerns by emailing cbd@royalcollege.ca. We’ll share them with our readers so everybody can learn from your experience.


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The faces of CBD

Early insights from the vice chair of education, department of surgery

Interview with
James Watterson, MD, FRCSC

Vice Chair of Education, Department of Surgery
Director of the Eric C. Poulin Office of Surgical Education
Associate Professor, University of Ottawa

My approach to CBD success as vice chair is similar to my approach as a program director: support, collaboration, advocacy and strong relationships with all program partners.

Urology, Surgical Foundations, Nephrology, Medical Oncology, Forensic Pathology and Emergency Medicine have joined Anesthesiology and Otolaryngology – Head and Neck Surgery in providing Competence by Design training this past July. In this issue of CBD Community Touchpoint, we talk with Vice Chair of Education Dr. James Watterson about his perspective of CBD implementation in Urology and lessons learned for the Department of Surgery at the University of Ottawa.

What do you see as the real advantage of CBD for residents?

One of the biggest advantages of CBD that I see is self-directed learning, which is the initial phase of continuing professional development and lifelong learning. I like that training is based on reflection and reassessment of important determinants of specialty training by educational leaders in respective fields. The improved documentation of a resident's progress should help to better assess their performance.

Residents come to work with a daily learning goal!

From your perspective, how aware is the chair community of CBD?

All chairs — whether they are vice chairs of education, departmental chairs or others — are aware of CBD. However, we are all in unfamiliar territory. The challenge that we face is that every program, in every academic centre, is trying to implement CBD in relative isolation. At the University of Ottawa, we are trying our best to share approaches to CBD implementation between programs, be it in surgical or medical specialties, subspecialties or programs.

Describe your role in implementing CBD.

My approach to CBD success as vice chair is similar to my approach as a program director: support, collaboration, advocacy and strong relationships with all program partners.

When I assumed the role of vice chair of education for the Department of Surgery at the University of Ottawa in January, I knew my main focus for my term would be to assist programs with the transition to CBD while supporting programs following accreditation in 2016. As past program director for Urology, I had been involved with CBD with our Royal College Specialty Committee since 2015. As such, I felt I would be uniquely positioned to help guide the transition of CBD within the Department of Surgery, using Urology as a framework and pilot program for CBD. It is my vision that important lessons can be learned and best practices established using a practical framework to help with the implementation of CBD across all surgical programs over the next five to seven years.

We have continued to grow the culture of formative, work-based assessments in Ottawa. For the past five years, we have been using the O-SCORE operating room assessment instrument. Residents and faculty have become familiar with conducting in the moment assessments on iPads. I believe this has prepared us for the transition to CBD on Elentra (the electronic portfolio platform being used at the University of Ottawa) where different types of work-based assessments will be completed as we assess residents’ entrustable professional activities (EPAs) and milestones.

Providing a practical framework for the implementation of CBD in programs has also begun. Our goal is to standardize as many processes with Urology and Surgical Foundations (e.g., competence committee terms of reference, curriculum mapping, work-based assessment templates, etc.) to streamline the onboarding of other medical specialty programs as they approach their CBD launch dates.

I believe there will be a need for more supports to help with CBD implementation. In the Eric C. Poulin Office of Education, important changes have already started. Office Director Christine Seabrook has been instrumental in supporting our CBD mandate. We envision the establishment of a centralized CBME (competency-based medical education) lead to help support and guide programs, program directors, program administrators and competence committees while liaising with the postgraduate medical education (PGME) office. We have also started to develop a data management position to assist competence committees with report generation from Elentra.

What challenges did you encounter? How did you, your program and your school overcome them?

Faculty engagement and buy-in are still real concerns. We recently held a CBD Information Night for the Department of Surgery faculty in preparation for the launch of Surgical Foundations, which will affect all surgical programs. Below is a word cloud that was generated from the attendees when they were asked about their concerns transitioning to CBD. Many themes were expressed:

  • managing evaluator fatigue, both for learner and mentor;
  • engaging faculty; and
  • potentially impacting faculty workload.
Word cloud

There were also many concerns raised about the lack of a working electronic portfolio to assist with data management and report generation. Our CBME leads in the PGME office have been working tirelessly with program directors of the 2018 cohort to set up Elentra.

Did you encounter any surprises?

The most surprising aspect has been the extremely varied level of understanding of CBD among faculty members. Despite Surgical Foundations having launched July 1, I feel many faculties, especially those who are in CBD-naïve programs, are still in the dark about CBD. Surgical Foundations Program Director Dr. Jeff Warren, along with Program Administrator Laura Gerridzen, has been active in educating the various programs about CBD for Surgical Foundations. The Office of Education is exploring innovative ways to further educate faculty about Surgical Foundations’ entrustable professional activities (EPAs) and milestones, such as the use of pocket reference cards.

What is important to keep in mind about the CBD implementation process?

Change is slow. There will be naysayers, hurdles and potential setbacks along the way. It is important to remain resolute and positive, focused on the end result, which is improving accountability and comprehensiveness of our residency training.

If you could say one thing about preparing to implement CBD to your counterpart at another school, what would that be?

Partnership with other CBD leaders in one's own centre is crucial. Identifying and communicating with individuals who are actively invested in the CBD process is a must. These individuals may be program directors, chairs from other specialties, PGME CBME leads and other support staff. As there is no right or wrong way of implementing CBD, it is important to be creative and open to many different processes and opinions. Build your team. Be practical!

“The greatest difficulty in life is to make knowledge effective, to convert it into practical wisdom.”

— Sir William Osler


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answers to Resident ePortfolio questions

Get the most out of Resident ePortfolio

An integral part of Competence by Design (CBD) is having regular, low-stakes, documented observations in the workplace. Competence committees use these data points to track residents’ learning progression over time.

The Royal College’s free Resident ePortfolio is one of the systems that captures this data, and as of July 1, nearly 800 residents at 11 medical schools were registered in the Resident ePortfolio system.

Webinar series helps residents preview ePortfolio

In preparation for a new cohort of residents starting CBD, the Royal College has developed a series of webinars to introduce residents and faculty to the system. Led by experts within the Royal College, these 45 minute webinars introduced key components, including uploading evidence and interpreting reports.

Missed the webinars? You can watch them here.

If you have specific questions, contact your local competency-based medical education (CBME) lead or program administrator. Find your CBME lead here.

Stay tuned: The Royal College is planning more Resident ePortfolio training webinars for other user groups — including competence committees and program administrators!


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The pioneers of earlier CBD exams

Medical student summit: Engaging the future in CBD

To engage residents in Competence by Design (CBD) earlier, the Royal College held a summit for the Canadian Federation of Medical Students and Fédération médicale étudiante du Québec. The full-day CBD summit was held at the end of April in Halifax, N.S., ahead of the Canadian Conference on Medical Education (CCME).

Enthusiasm was felt throughout the room, and by the end of the day, many students mentioned that they intend to become further engaged in local CBD implementation.

“It was so inspiring to spend time with these folks who see CBD as their future and are motivated to take an active role in their learning, so they can live it going forward”, said Change Advisor Rhonda St. Croix, who was one of the presenters.

“My experience with the Royal College, as well as with local school administrators, has shown me that a learner’s voice is valued,” said Silvio Ndoja, a medical student at Western University. “We are in an era of change, and I am glad that CBD is being embraced. In this era of change, we must work together to identify areas of improvement and work on them.”

What excites him about CBD is the fact that learners are better informed about what is expected of them, so they are better able to take charge of their own learning. “I did my undergrad in Biology and Psychology and did research in pedagogy, so this resonates strongly with me. The intense research in medical education will lead to a better understanding of how to better train physicians, and this will in the end benefit both the learners and the public.”

Other presenters at the medical student summit included Deputy CEO and Executive Director of Specialty Education Ken Harris, Clinical Educator Adelle Atkinson, International Conference on Residency Education (ICRE) Program Advisory Board member and Clinical Educator Brie Yama, CBD Administrative Coordinator Natasha Bernardi, and a couple of residents in CBD programs. Magalie Beauregard and Leora Branfield Day of Fédération des médecins résidents du Québec (FMRQ) and Resident Doctors on Canada (RDoC) also attended. They facilitated interactive sessions to support and empower medical students in preparation for a CBD residency. They explored the current system of residency education; the rationale for CBD; key concepts, terminology and key practices (growth mindset, feedback, coaching and change); and dispelled myths and misconceptions.

As a group activity, the medical students explored how a resident’s mindset can affect their success in a CBD training program. Individually, they completed a quick self-reflection quiz to advance their learning.

In the last session, they created action plans to engage their peers in CBD and presented their ideas to the student spring general assembly the next day.

The Royal College encourages program directors to discuss CBD with medical students during their CaRMS interviews in January. You can find useful resources for residents and medical students by clicking here.


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Learning from FMRQ’s report on CBD

One of the earliest and most comprehensive studies of Competence by Design implementation is the Fédération des médecins résidents du Québec (FMRQ) report, The Impact of Competence by Design.

The report provides helpful insights based on the experiences and observations of 2017-2018 first-year residents in Anesthesiology and Otolaryngology — Head and Neck Surgery at Quebec’s four medical schools. The FMRQ presented its report to the Committee on Specialty Education in early May to help the Royal College and other stakeholders learn from their members’ experiences.

In the report, the FMRQ concluded that its “observations are sometimes inspiring, sometimes troubling, but they certainly provide food for thought.”

Royal College Deputy CEO and Executive Director of Specialty Education, Ken Harris, agrees with that sentiment. “The journey to meaningful and sustainable change always involves progress, promise and setbacks. Change takes time, it’s dependent on context, and it must be studied and adapted through iterative cycles of feedback and learning,” he said. “The Royal College appreciates the FMRQ’s efforts to contribute valuable input into the learning and growth of CBD.”

Collaborative continuous improvement requires feedback from all partners and stakeholders. An important role of the Royal College in the success of CBD is sharing information and establishing best-practices based on what we have learned collectively.

The FMRQ conducted semi-structured interviews with 32 residents in January and February, six months after they started CBD training.

“We recognize that CBD implementation is a complex series of interventions, actions and learning by a multitude of stakeholders, particularly faculty, residents and postgraduate medical education offices,” Harris said. “The table below outlines actions that the Royal College has taken to address the recommendations. We look forward to more collaborating, linking and learning from partners as they develop their responses and actions. Together we will learn and grow.”

Read full FMRQ report

FMRQ Report Summary

FMRQ Recommendations

  1. Clarity surrounding how CBD affects the length of training.
  2. The Royal College is producing a new policy, The Role of Time in CBD, which will be widely distributed this fall. An excerpt below helps to clarify: Which elements of residency training will remain time-dependent?

    In choosing a hybrid model approach, we avoid the need for a major overhaul of current, time-based structures. Therefore, it is expected that some elements of a resident’s training experience will remain time-dependent. These may include:

    • Clinical placements and agreements with the University/Hospital/Ministries of Health
    • PGY funding
    • Program/discipline matches
    • Royal College examinations offered once per year
  3. Provide more information sooner.
  4. Advice on timing and process:
    • Departments and programs should be responsible for ensuring evaluation forms are completed within a reasonable timeframe. Coaching Model Video
    • A policy allowing for alternatives should be provided to enable residents to progress in the event of extended breaks in service. Ongoing Resident ePortfolio Updates
    • Programs should provide residents with a schedule matching each EPA with a specific rotation conducive to its evaluation. Curriculum Mapping
    • Progression in EPAs during off-service rotations should be fostered. How-To Guide (in development)
    • Faculties should clearly set out each stakeholder’s roles and responsibilities in CBD. Change Checklist
    • Faculties and the programs should be aware of the additional workload and stress that CBD brings. Instructions for Facilitators: Implementation and Readiness Presentation
  5. The Royal College’s specialty committees should be mindful of the number of EPAs, milestones and observations that need to be attained. As well, it must be made clear that elements of CBD such as this are presented as guidelines that could be subject to adjustments post-implementation.
  6. Continuous improvement measures should be implemented in a long-term perspective.

Top 3 CBD resources for residents

Looking to engage and prepare residents for the transition to CBD? Check out our top resources to help them take control of their learning!

  1. Competence by Design — Residents: Key things you need to know. CBD may seem daunting, but this infographic for residents quickly and easily shows what they need to know. It highlights eight key elements that define what CBD means to residency training.
  2. CBD: What you need to know — A resident's guide. Designed for residents, this four-page document introduces the concepts of CBD to help explain the changes ahead.
  3. A Resident's orientation to CBD — Program directors can customize this 39-slide presentation for their school and discipline to help prepare residents for CBD.


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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.