Competency-structured case discussion in the morning meeting: enhancing CanMEDS integration in daily practice

Figures & data

Table 1 The CanMEDS competencies

CanMEDS role	Description
Medical expert	“Demonstrate diagnostic and therapeutic skills for ethical and effective patient care, access and apply relevant information to clinical practice and demonstrate effective consultation services with respect to patient care, education and legal opinions”
Communicator	“Obtain and synthesize relevant history from patients/families/communities, listen effectively and discuss appropriate information with patients/families and the health care team”
Collaborator	“The physician must consult effectively with other physicians and health care professionals and contribute effectively to other interdisciplinary activities”
Scholar	“Develop, implement and monitor and professional continuing education strategy, critically appraise sources of medical information, facilitate learning of patients, house staff/students and other health professionals and contribute to the development of new knowledge”
Advocate	“Identify the important determinants of health affecting patients, contribute effectively to improved health of patients and communities and recognize and respond to those issues where advocacy is appropriate”
Manager	“Utilize resources effectively to balance patient care, learning needs and outside activities, allocate finite health care resources wisely, work effectively and efficiently in a health care organization and utilize information technology to optimize patient care, life-long learning and other activities”
Professional	“Deliver the highest quality of care with integrity, honesty and compassion, exhibit appropriate personal and interpersonal professional behaviors and practice medicine ethically consistent with obligations of a physician”

Abbreviation: CanMEDS, Canadian Medical Education Directives for Specialists.

Table 2 Post-CanMEDS-structured morning meeting questionnaire

Last 4 digits of mobile no:
Grade: R1□	R2□	R3□	R4□
Compared to your understanding of the CanMEDS roles on a patient with COPD exacerbation prior to this session:
Question				Agree	Neither agree or disagree/neutral	Disagree
1. You previously had a good idea on how to apply all the CanMEDS competencies in such a patient
2. You previously had a good idea on how to apply some of the CanMEDS competencies in such a patient
3. You are now more competent in the Medical Expert Role
4. Mention one new interesting knowledge on the Medical Expert role:………………………………
5. You are now more competent in the Collaborator Role Mention one new interesting knowledge on the Collaborator role:………………………………
6. You are now more competent in the Scholar Role
7. Mention one new interesting knowledge on the Scholar role:………………………………
8. You are now more competent in the Health Advocate Role
9. Mention one new interesting knowledge on the Advocate role:………………………………
10. You are now more competent in the Manager Role
11. Mention one new interesting knowledge on the Manager role:………………………………
12. You are now more competent in the Communicator Role
13. Mention one new interesting knowledge on the Communicator role:………………………………
14. You are now more competent in the Professional Role
15. Mention one new interesting knowledge on the Professional role:………………………………
A CanMEDS-structured case discussion improves my skills in caring for my patients
This method of case presentation should be continued

Abbreviations: CanMEDS, Canadian Medical Education Directives for Specialists; COPD, chronic obstructive airways disease; R, year of residence.

Table 3 Examples of CanMEDS-guided approach to manage a patient with a COPD exacerbation

CanMEDS role	Examples
Medical expert	• This patient has multiple comorbidities. As a medical expert how would you guarantee a holistic approach to her care?
	• What are the criteria for diagnosing an exacerbation in patients with COPD?
	• How may one classify the causes of COPD exacerbations?
	• How may a physician assess an exacerbation to determine severity and site of care?
	• What investigations are necessary in the hospital?
	• How would you decide that a particular patient needs to be on controlled-oxygen therapy?
	• What are the limitations of using pulse oximetry in assessing oxygenation in patients with relatively advanced COPD and smokers?
	• How is a COPD acute exacerbation managed?
	• What is the prognosis for patients with an exacerbation?
	• How may one assess the risk for re-hospitalization in a patient with COPD?
Communicator	• Proper/comprehensive H&P and develop rapport and trust
	• Consultation skills
	• Breaking bad-news
	• Living will/end-of-life care
Collaborator	• Respiratory physicians
	• Pulmonary educators
	• Physiotherapists/respiratory therapists
	• Social worker
	• COPD specialist nurse
	• Smoking cessation service
	• Dietitian
Scholar	• How do you access the guidelines for COPD/stay-up-to-date?
	• What are the sensitivity, specificity, and likelihood ratios for symptoms, signs, and tests used to differentiate between left ventricular failure (pulmonary edema) and COPD exacerbation in such a patient?^Citation9
	• What is the number needed to treat (NNT) for LTOT?
	• What is the prognostic magnitude of smoking cessation in COPD?
Advocate	• Patient education: disease, treatment, inhaler devices skills, trigger avoidance, travel, etc
	• Deep venous thrombosis prophylaxis
	• Smoking cessation
	• Social, psychological, occupational, and financial support
	• Influenza and pneumococcal vaccination
	• Self-management plan, when to seek medical care
	• COPD alert card (for patients with previous episode of CO2 narcosis)
	• Screening for osteoporosis
	• Screening for obstructive sleep apnea
	• Screening for depression
	• Membership of patient societies
	• Consideration of home oxygen
	• Arranging for follow-up
	• Referral to pulmonary rehabilitation service
	• Local and national campaigns: educational, antismoking, etc.
Manager	• How do you streamline and improve the quality of care for patients with COPD exacerbation?
	• How do you expedite the discharge process for patients with COPD?
	• How do you reduce readmission rates for this patient?
	• Quality indicators/audit of COPD care
	• Economic comparisons of various interventions
Professional	Ethical issues:
	• Intubation or not
	• Patient using unorthodox treatments
	• Refusing steroid therapy
	• Requesting therapy that is not recommended, eg, alpha-1 antitrypsin replacement therapy

Abbreviations: CanMEDS, Canadian Medical Education Directives for Specialists; COPD, chronic obstructive airways disease; H&P, history and physical examination; NNT, number need to treat; LTOT, long-term oxygen therapy; CO₂, carbon dioxide.

Table 4 Results of post-exercise questionnaire

	Agree (%)	Neutral (%)	Disagree (%)
Good prior understanding of all CanMEDS roles	9 (45)	Nil	11 (55)
Good prior understanding of some CanMEDS roles	13 (65)	3 (15)	4 (20)
Post-exercise improved competency of medical expert role	16 (80)	2 (10)	2 (10)
Post-exercise improved competency of communicator role	18 (90)	2 (10)	Nil
Post-exercise improved competency of scholar role	17 (85)	2 (10)	1 (5)
Post-exercise improved competency of advocate role	18 (90)	2 (10)	Nil
Post-exercise improved competency of collaborator role	15 (75)	4 (20)	1 (5)
Post-exercise improved competency of professional role	15 (75)	2 (10)	3 (15)
Post-exercise improved competency of manager role	14 (70)	4 (20)	2 (10)
CanMEDS-structured case discussion improves my skills in caring for my patients	16 (80)	4 (20)	Nil
This method of case presentation should be continued	17 (85)	2 (10)	1 (5)

Abbreviation: CanMEDS, Canadian Medical Education Directives for Specialists.

Table 5 Residents’ input on the scholar and advocate roles

Scholar role	Number	%	Advocate role	Number	%
Staying up-to-date	5	29.4	Referral to home health care	2	13.3
Evidence-based medicine in COPD	1	5.9	Providing home oxygen	1	6.7
Educating residents	1	5.9	Referral to pulmonary service	2	13.3
Educating patients on COPD	1	5.9	Referral to pulmonary rehabilitation	1	6.7
Educating patients on how to use medications	1	5.9	Screening for systemic complications (depression)	2	13.3
New evidence in treatment	1	5.9	Providing a self-management plan	2	13.3
Likelihood ratio	1	5.9	Advice on smoking cession	1	6.7
NNT	2	11.6	Dealing with social needs	1	6.7
NNT for home oxygen therapy	2	11.6	Vaccination	2	13.3
Role of azithromycin	1	5.9	Vaccination and social services	1	6.7
Searching for COPD treatment guidelines	1	5.9
Total number answering	17	85	Total number answering	15	75

Abbreviations: COPD, chronic obstructive airways disease; NNT, number need to treat.

WangCSFitzgeraldJMShulzerMMakEAyasNTDoes this dyspneic patient in the emergency department have congestive heart failure?BaughmanKLBaumgartnerWAThe Rational Clinical Examination Chap 16New YorkJAMA, McGraw-Hill Book200919441956

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