Validating objectives and training in Canadian paediatrics residency training programmes

Figures & data

Table

Practice points

Determination of training–practice gap scores allows assessment of competencies required to function as consultant paediatricians, and how residency training has prepared paediatricians for practice. Measuring the gap between importance and preparedness is very useful in validating objectives of training. This methodology could prove to be useful across medical specialties to review and validate their objectives of training, and to better define the competencies required for consultant practice. There is a need for ongoing monitoring of competencies acquired during residency training and preparedness for practice.

Table 1.  The Purpose of this questionnaire is to determine your opinion about what clinical competencies should be acquired during paediatric residency training so that a graduating trainee can practice as a consultant paediatrician

Conditions/disorders/disease/problems/tasks Q1. For paediatricians		Not important	Somewhat important	Important	Very important	Extremely important
Q2. For paediatricians		Not prepared	Somewhat prepared	Adequately prepared	Very well prepared	Extremely well prepared
Acute care	Obtaining intravenous access in infants, children and youth	1	2	3	4	5
	Gastroenteritis, dehydration and prescribing and managing fluids and electrolytes in all age groups	1	2	3	4	5
	Endotracheal intubation in newborn, children and youth	1	2	3	4	5
	Performing thoracentesis and chest tube placement	1	2	3	4	5
	Provision of cardiopulmonary resuscitation in multidisciplinary teams and participation in mock codes in newborn, children and youth	1	2	3	4	5
	Diagnosing and managing shock	1	2	3	4	5
	Determining if urgent consultation or transport is required for a sick infant/child/youth	1	2	3	4	5
	Applying ethical principles to provision or withholding of clinical care, patient confidentiality and informed consent	1	2	3	4	5
	Crisis resource management training (leadership, problem solving, situational awareness, communication skills and resource management) including communicating information and providing support in a crisis situation (e.g. unexpected death)	1	2	3	4	5
	Interpreting abdominal and chest X-rays and, interpreting skeletal and bone X-rays for fractures	1	2	3	4	5
GI and nutrition	Recurrent abdominal pain including constipation as a cause	1	2	3	4	5
	Failure to thrive, growth problems, gastroesophageal reflux and feeding disorders	1	2	3	4	5
	Hepatomegaly, hepatitis	1	2	3	4	5
	Obesity	1	2	3	4	5
	Iron deficiency	1	2	3	4	5
	Prescribing and managing parenteral nutrition	1	2	3	4	5
Cardiovascular	Congenital heart disease, heart murmurs	1	2	3	4	5
	Syncope, cardiac arrhythmias	1	2	3	4	5
	Interpreting ECGs in all age groups (0–18 years)	1	2	3	4	5
ENT and respiratory	Pharyngitis and tonsillitis, sinusitis	1	2	3	4	5
	Otitis media	1	2	3	4	5
	Hearing loss and hearing assessment	1	2	3	4	5
	Snoring and sleep apnea	1	2	3	4	5
	Asthma, bronchiolitis, croup, tracheo-bronchitis	1	2	3	4	5
	Pneumonia	1	2	3	4	5
	Performing and interpreting oximetry	1	2	3	4	5
	Demonstrating to patient/parent the use of devices used for drug administration for asthma and the use of an epipen	1	2	3	4	5
Allergy and immunology	Allergy and immunologic problems, drug allergy, food allergy and anaphylaxis	1	2	3	4	5
Endocrine	Type I and type II diabetes	1	2	3	4	5
	Disorders of puberty and sexual development	1	2	3	4	5
	Thyroid disease	1	2	3	4	5
Hematology and oncology	Red cell disorders, platelet disorders and hemorrhagic conditions	1	2	3	4	5
	Childhood neoplasms, leukaemia and lymphoma	1	2	3	4	5
Renal and GU	Urinary tract infection, Vesico-ureteric reflux	1	2	3	4	5
	Acute and chronic renal failure	1	2	3	4	5
	Hypertension	1	2	3	4	5
	Undescended testis, hypospadias	1	2	3	4	5
	Menstrual cycle irregularities and menorrhagia	1	2	3	4	5
Mental health	Conducting a mental status examination	1	2	3	4	5
	Anxiety disorders, phobias and obsessive compulsive disorders	1	2	3	4	5
	Depression	1	2	3	4	5
	Attempted suicide	1	2	3	4	5
	Psychosomatic conditions	1	2	3	4	5
	Violent behaviour	1	2	3	4	5
ID	Common bacterial and viral infections	1	2	3	4	5
	Infection preventive strategies and immunization counselling	1	2	3	4	5
	Uncommon but re-emerging infection-related chronic diseases such as tuberculosis, rheumatic fever	1	2	3	4	5
	Cellulitis, orbital cellulitis, necrotizing fasciitis	1	2	3	4	5
Dermatology	Acne, eczema and other dermatidites	1	2	3	4	5
	Pigmentary and vascular lesions (e.g. nevi, hemangiomas)	1	2	3	4	5
CNS and ophthalmology	Epilepsy, seizures	1	2	3	4	5
	Headaches	1	2	3	4	5
	Intracranial haemorrhage and stroke	1	2	3	4	5
	CNS infections, meningitis	1	2	3	4	5
	Floppy infant	1	2	3	4	5
	Red eye	1	2	3	4	5
	Strabismus, vision assessment	1	2	3	4	5
Newborn	Disorders associated with prematurity and low birth weight	1	2	3	4	5
	Respiratory distress syndrome and other respiratory disorders of newborn infants	1	2	3	4	5
	Common neonatal problems (e.g. jaundice, sepsis)	1	2	3	4	5
	Neonatal hypoglycaemia	1	2	3	4	5
Surgery, trauma and MSK	Appendicitis	1	2	3	4	5
	Bowel obstruction, intussusception	1	2	3	4	5
	Non-life-threatening trauma, head trauma, fractures and burns	1	2	3	4	5
	Congenital dislocation of hip	1	2	3	4	5
	Scoliosis	1	2	3	4	5
	Gait disorders, joint and limb pain	1	2	3	4	5
	Septic arthritis and osteomyelitis	1	2	3	4	5
Development/behaviour	Colic	1	2	3	4	5
	Assessing developmental milestones, psychomotor development	1	2	3	4	5
	Developmental delay, mental retardation, developmental regression	1	2	3	4	5
	Providing anticipatory guidance and well child/youth care	1	2	3	4	5
	Attention deficit disorders with or without hyperactivity	1	2	3	4	5
	Learning disability, communicating with school regarding learning problems	1	2	3	4	5
	Behaviour and conduct disorders	1	2	3	4	5
	Autism spectrum disorders, pervasive developmental disorders	1	2	3	4	5
Adolescent medicine	Assessing adolescent/youth (using HEEADSS format)	1	2	3	4	5
	Gynecomastia	1	2	3	4	5
	Risk taking (alcohol, drug, tobacco, and substance abuse),delinquency and sexually transmitted infections	1	2	3	4	5
	Contraception	1	2	3	4	5
Genetics and metabolics	Approach to investigating a dysmorphic child including Down syndrome, Turner syndrome, Fragile X syndrome, Prader–Willi syndrome, Klinefelter syndrome	1	2	3	4	5
	Genetic counselling for minor dysmorphic findings (e.g. vascular malformations, nevi, skin tags) and chromosomal anomalies (e.g. Down syndrome)	1	2	3	4	5
	Workup of infant/child with suspected inborn error of metabolism	1	2	3	4	5
Child/youth maltreatment	Managing children/youth with neglect and/or living in an abusive environment	1	2	3	4	5
	Managing children/youth who are victims of abuse (emotional, physical and/or sexual)
	Providing care to disadvantaged children and advocating for their health care needs	1	2	3	4	5
Continuing care	Children with complex/chronic problems (e.g. post-organ transplant, cerebral palsy, cystic fibrosis, chronic lung disease, short gut syndrome)	1	2	3	4	5
	Dealing with cultural and ethnic differences in a diverse patient population	1	2	3	4	5
	Assisting patients/parents in dealing with and navigating our health care system	1	2	3	4	5
	Managing an efficient work place/office	1	2	3	4	5
	Practicing cost-effective health care	1	2	3	4	5
	Performing practice-based improvement activities, conducting critical appraisal of literature and/or participating in research related to child health	1	2	3	4	5

Notes: Two questions will be asked about each condition/problem/task.

Q1. How important is the competency of diagnosing (including performing tasks) and managing the following for your practice?

Q2. How well prepared were you at the start of your paediatric consultant practice in diagnosing (including performing tasks) and managing the following?

Table 2.  Responses regarding importance and preparedness (based on 5-point Likert-scale) and gap scores

Classification domains	Number of items	Mean importance	Mean preparedness	Mean raw gap score*	Mean gap score (%)**	p-value
Mental health	6	3.5	2.33	1.17	23.4	<0.001
Development/behaviour	8	3.94	2.97	0.97	19.4	<0.001
Continuing care	6	3.70	2.96	0.74	14.8	<0.001
Cardiovascular	3	3.83	3.13	0.70	14.0	<0.001
Allergy and immunology	1	4.00	3.30	0.70	14.0	<0.001
Acute care	10	3.90	3.31	0.59	11.8	<0.001
Dermatology	2	3.66	3.08	0.58	11.6	<0.001
CNS and ophthalmology	7	3.80	3.25	0.55	11.0	<0.001
Adolescent medicine	4	3.48	3.07	0.41	8.2	<0.001
Renal and GU	5	3.61	3.2	0.41	8.2	<0.001
Endocrine	3	3.56	3.16	0.40	8.0	<0.001
Surgery, trauma and MSK	7	3.59	3.24	0.35	7.0	<0.001
GI and nutrition	6	3.78	3.49	0.29	5.8	<0.001
Hematology and oncology	2	3.56	3.28	0.28	5.6	0.005
ENT and respiratory	8	3.91	3.64	0.27	5.4	<0.001
Infectious diseases	4	4.03	3.76	0.27	5.4	<0.001
Newborn	4	4.11	4.02	0.09	1.8	0.34
Genetics and metabolics	3	3.12	3.54	−0.42	−8.4	<0.001
Child/youth maltreatment	3	2.74	3.84	−1.10	−22.0	<0.001

Notes: *Mean raw gap score = mean importance – mean preparedness.

**Mean gap score (%) = (mean raw gap score/5) × 100.

Table 3.  Gap scores for all 92 competencies surveyed

Conditions/Disorders/Disease/Problems/Tasks		Mean importance	Mean preparedness	Raw gap score	Gap score (%)	Significance p (two-tailed)
Acute care	Obtaining intravenous access in infants, children and youth	3.49	2.53	0.96	19	<0.001
	Gastroenteritis, dehydration and prescribing and managing fluids and electrolytes in all age groups	4.47	4.44	0.03	1	0.698
	Endotracheal intubation in newborn, children and youth	3.84	3.29	0.55	11	<0.001
	Performing thoracentesis and chest tube placement	2.60	2.05	0.54	11	<0.001
	Provision of cardiopulmonary resuscitation in multidisciplinary teams and participation in mock codes in newborn, children and youth	3.86	3.33	0.53	11	<0.001
	Diagnosing and managing shock	4.30	4.09	0.21	4	0.028
	Determining if urgent consultation or transport is required for a sick infant/child/youth	4.37	3.87	0.50	10	<0.001
	Applying ethical principles to provision or withholding of clinical care, patient confidentiality and informed consent	4.13	3.40	0.72	14	<0.001
	Crisis resource management training (leadership, problem solving, situational awareness, communication skills and resource management) including communicating information and providing support in a crisis situation (e.g. unexpected death)	4.03	2.92	1.11	22	<0.001
	Interpreting abdominal and chest X-rays and, interpreting skeletal and bone X-rays for fractures	3.90	3.16	0.74	15	<0.001
GI and nutrition	Recurrent abdominal pain including constipation as a cause	4.06	3.82	0.24	5	0.002
	Failure to thrive, growth problems, gastroesophageal reflux and feeding disorders	4.34	3.82	0.52	10	<0.001
	Hepatomegaly, hepatitis	3.35	3.10	0.25	5	0.001
	Obesity	3.89	3.11	0.77	15	<0.001
	Iron deficiency	4.08	3.99	0.09	2	0.440
	Prescribing and managing parenteral nutrition	2.97	3.06	−0.09	-2	0.427
Cardiovascular	Congenital heart disease, heart murmurs	4.11	3.41	0.71	14	<0.001
	Syncope, cardiac arrhythmias	3.64	3.08	0.55	11	<0.001
	Interpreting ECGs in all age groups (0–18 years)	3.74	2.88	0.85	17	<0.001
ENT and respiratory	Pharyngitis and tonsillitis, Sinusitis	3.85	3.72	0.14	3	0.129
	Otitis media	4.02	3.93	0.09	2	0.320
	Hearing loss and hearing assessment	3.47	2.77	0.70	14	<0.001
	Snoring and sleep apnea	3.48	3.02	0.46	9	<0.001
	Asthma, bronchiolitis, croup, tracheo-bronchitis	4.51	4.36	0.15	3	0.075
	Pneumonia	4.44	4.34	0.09	2	0.181
	Performing and interpreting oximetry	3.68	3.51	0.17	3	0.088
	Demonstrating to patient/parent the use of devices used for drug administration for asthma and the use of an epipen	3.89	3.47	0.42	8	0.001
Allergy and immunology	Allergy and immunologic problems, drug allergy, food allergy and anaphylaxis	4.00	3.29	0.71	14	<0.001
Endocrine	Type I and type II diabetes	3.81	3.36	0.45	9	<0.001
	Disorders of puberty and sexual development	3.45	3.06	0.39	8	0.001
	Thyroid disease	3.41	3.06	0.35	7	0.001
Hematology and oncology	Red cell disorders, platelet disorders and hemorrhagic conditions	3.57	3.21	0.36	7	<0.001
	Childhood neoplasms, leukaemia and lymphoma	3.57	3.37	0.20	4	0.095
Renal and GU	Urinary tract infection, Vesico-ureteric reflux	4.23	3.97	0.26	5	0.002
	Acute and chronic renal failure	3.59	3.10	0.49	10	<0.001
	Hypertension	3.70	3.11	0.58	12	<0.001
	Undescended testis, hypospadias	3.35	3.20	0.16	3	0.083
	Menstrual cycle irregularities and menorrhagia	3.17	2.60	0.57	11	<0.001
Mental health	Conducting a mental status examination	3.20	2.51	0.69	14	<0.001
	Anxiety disorders, phobias and obsessive compulsive disorders	3.54	2.17	1.38	28	<0.001
	Depression	3.67	2.39	1.28	26	<0.001
	Attempted suicide	3.51	2.49	1.01	20	<0.001
	Psychosomatic conditions	3.57	2.41	1.16	23	<0.001
	Violent behaviour	3.47	2.01	1.46	29	<0.001
ID	Common bacterial and viral infections	4.48	4.25	0.23	5	0.002
	Infection preventive strategies and immunization counselling	4.14	3.95	0.19	3.8	0.007
	Uncommon but re-emerging infection related chronic diseases such as tuberculosis, rheumatic fever	3.47	3.07	0.40	8	<0.001
	Cellulitis, orbital cellulitis, necrotizing fasciitis	3.91	3.81	0.10	2	0.243
Dermatology	Acne, eczema and other dermatidites	3.95	3.32	0.63	13	<0.001
	Pigmentary and vascular lesions (e.g. nevi, hemangiomas)	3.2	2.86	0.34	6.8	<0.001
CNS and ophthalmology	Epilepsy, seizures	4.01	3.39	0.63	13	<0.001
	Headaches	4.04	3.71	0.34	7	0.002
	Intracranial haemorrhage and stroke	3.39	2.89	0.50	10	<0.001
	CNS infections, meningitis	4.32	4.16	0.16	3	0.015
	Floppy infant	3.89	3.25	0.64	13	<0.001
	Red eye	3.41	2.93	0.48	10	<0.001
	Strabismus, vision assessment	3.57	2.46	1.11	22	<0.001
Newborn	Disorders associated with prematurity and low birth weight	4.02	3.77	0.25	5	0.017
	Respiratory distress syndrome and other respiratory disorders of newborn infants	4.15	4.06	0.08	2	0.440
	Common neonatal problems (e.g. jaundice, sepsis)	4.24	4.25	-0.01	0	0.902
	Neonatal hypoglycaemia	4.02	4.02	0	1.0	1.000
Surgery, trauma and MSK	Appendicitis	3.61	3.55	0.06	1	0.482
	Bowel obstruction, intussusception	3.66	3.54	0.12	3	.0.170
	Non-life-threatening trauma, head trauma, fractures and burns	3.53	2.89	0.63	13	<0.001
	Congenital dislocation of hip	3.63	3.25	0.38	8	0.001
	Scoliosis	3.35	2.85	0.49	10	<0.001
	Gait disorders, joint and limb pain	3.56	2.94	0.62	12	<0.001
	Septic arthritis and osteomyelitis	3.78	3.67	0.11	2	0.260
Development/behaviour	Colic	3.75	3.43	0.32	6	0.006
	Assessing developmental milestones, psychomotor development	4.20	3.48	0.72	14	<0.001
	Developmental delay, mental retardation, developmental regression	4.15	3.33	0.82	16	<0.001
	Providing anticipatory guidance and well child/youth care	3.87	3.09	0.79	16	<0.001
	Attention deficit disorders with or without hyperactivity	4.03	2.94	1.09	22	<0.001
	Learning disability, communicating with school regarding learning problems	4.00	2.43	1.57	31	<0.001
	Behaviour and conduct disorders	3.77	2.27	1.50	30	<0.001
	Autism spectrum disorders, pervasive developmental disorders	3.84	2.81	1.03	21	<0.001
Adolescent medicine	Assessing adolescent/youth (using HEEADSS format)	3.94	3.75	0.19	4	0.077
	Gynecomastia	3.06	2.80	0.27	5	0.0130
	Risk taking (Alcohol, drug, tobacco, and substance abuse),delinquency and sexually transmitted infections	3.66	3.07	0.59	12	<0.001
	Contraception	3.27	2.66	0.61	12	<0.001
Genetics and metabolics	Approach to investigating a dysmorphic child including Down syndrome, Turner syndrome, Fragile X syndrome, Prader–Willi syndrome, Klinefelter syndrome	3.72	3.27	0.46	9	<0.001
	Genetic counselling for minor dysmorphic findings (e.g. vascular malformations, nevi, skin tags) and chromosomal anomalies (e.g. Down syndrome)	2.78	3.56	−0.78	−16	<0.001
	Workup of infant/child with suspected inborn error of metabolism	2.87	3.80	−0.93	−19	<0.001
Child/youth maltreatment	Managing children/youth with neglect and/or living in an abusive environment	2.85	3.73	−0.87	−17	<0.001
	Managing children/youth who are victims of abuse (emotional, physical and/or sexual)	2.62	3.94	−1.32	−26	<0.001
	Providing care to disadvantaged children and advocating for their health care needs	2.76	3.85	−1.10	−22	<0.001
Continuing care	Children with complex/chronic problems (e.g. post-organ transplant, cerebral palsy, cystic fibrosis, chronic lung disease, short gut syndrome)	3.28	3.88	−0.60	−12	<0.001
	Dealing with cultural and ethnic differences in a diverse patient population	3.24	3.77	−0.52	−10	<0.001
	Assisting patients/parents in dealing with and navigating our health care system	3.77	2.95	0.82	16	<0.001
	Managing an efficient work place/office	4.12	1.85	2.27	45	<0.001
	Practicing cost effective health care	3.89	2.26	1.63	33	<0.001
	Performing practice-based improvement activities, conducting critical appraisal of literature and/or participating in research related to child health	3.88	3.07	0.81	16	<0.001

Table 4.  Competencies rated as very important to diagnose and manage (mean importance ≥4)

Classification domain	Competency	Mean importance	Mean preparedness	Gap score (%)	Significance (two-tailed t-test) p
ENT and respiratory	Asthma, bronchiolitis, croup, tracheo-bronchitis	4.51	4.36	3	0.075
ID	Common bacterial and viral infections	4.48	4.25	5	0.002
GI and nutrition	Gastroenteritis, dehydration and prescribing and managing fluids and electrolytes	4.47	4.44	1	0.698
ENT and respiratory	Pneumonia	4.44	4.34	2	0.181
Acute care	Determining if urgent consultation or transport is required for a sick child	4.37	3.87	10	<0.001
GI and nutrition	Failure to thrive, growth problems, gastroesophageal reflux and feeding disorders	4.34	3.82	10	<0.001
CNS and ophthalmology	CNS infections, meningitis	4.32	4.16	3	0.015
Acute care	Diagnosing and managing shock	4.30	4.09	4	0.028
ID	Infection prevention strategies and immunization counselling	4.26	3.91	7	<0.001
Newborn	Common neonatal problems (e.g., jaundice, sepsis)	4.24	4.25	−0.01	0.902
Renal and GU	Urinary tract infection, Vesico-ureteric reflux	4.23	3.97	5	0.002
Development/behaviour	Assessing developmental milestones, psychomotor development	4.20	3.48	14	<0.001
Development/behaviour	Developmental delay, mental retardation, developmental regression	4.15	3.33	16	<0.001
Newborn	Respiratory distress syndrome and other respiratory disorders of newborn infants	4.15	4.06	2	0.440
Acute care	Applying ethical principles to provision or withholding of clinical care, patient confidentiality and informed consent	4.13	3.40	14	<0.001
Continuing care	Managing an efficient work place/office	4.12	1.85	45	<0.001
Cardiovascular	Congenital heart disease, heart murmurs	4.11	3.41	14	<0.001
GI and nutrition	Iron deficiency	4.08	3.99	2	0.200
GI and nutrition	Recurrent abdominal pain including constipation as a cause	4.06	3.82	5	0.002
CNS and ophthalmology	Headaches	4.04	3.71	7	0.002
Acute care	Crisis resource management training including communicating information and providing support in crisis situation	4.03	2.92	22	<0.001
Development/behaviour	Attention deficit disorders with or without hyperactivity	4.03	2.94	22	<0.001
Newborn	Disorders associated with prematurity and low birth weight	4.02	3.77	5	0.017
Newborn	Neonatal hypoglycaemia	4.02	4.02	0	1.0
ENT and respiratory	Otitis media	4.02	3.93	2	0.32
CNS and ophthalmology	Epilepsy, seizures	4.01	3.39	13	<0.001
Allergy and immunology	Allergy and immunology problems, drug/food allergy, anaphylaxis	4.00	3.29	14	<0.001
Development/behaviour	Learning disability, communicating with school regarding learning problems	4.00	2.43	31	<0.001

Table 5.  Competencies rated as less than adequately prepared for (mean preparedness score <3.00)

Classification domain	Competency/task	Mean preparedness
Continuing care	Managing an efficient work place/office	1.85
Mental health	Violent behaviour	2.01
Acute care	Performing thoracentesis and chest tube placement	2.05
Mental health	Anxiety disorders, phobias and obsessive compulsive disorders	2.17
Continuing care	Practicing cost-effective health care	2.26
Development and behaviour	Behaviour and conduct disorders	2.27
Mental health	Depression	2.39
Mental health	Psychosomatic conditions	2.41
Development and behaviour	Learning disability, communicating with school regarding learning problems	2.43
CNS and ophthalmology	Strabismus and vision assessment	2.46
Mental health	Attempted suicide	2.49
Mental health	Conducting a mental status examination	2.51
Acute care	Obtaining intravenous access in infants, children and youth	2.53
Renal and GU	Menstrual cycle irregularities and menorrhagia	2.60
Adolescent medicine	Contraception	2.66
ENT and respiratory	Hearing loss and hearing assessment	2.77
Development and behaviour	Autism spectrum disorders, pervasive developmental disorders	2.81
Cardiovascular	Interpreting ECGs (0–18 years)	2.88
Surgery, trauma and MSK	Non-life threatening trauma, head trauma, fractures and burns	2.89
Acute care	Crisis resource management	2.92
Development and behaviour	Attention deficit disorders with or without hyperactivity	2.94
Surgery, trauma and MSK	Gait disorders, joint and limb pain	2.94
Continuing care	Assisting patients/parents in dealing with and navigating health care system	2.95

Table 6.  Competencies/performing tasks with gap scores >10% and p < 0.001

Classification domain	Competency/task	Mean importance	Mean preparedness	Gap score (%)
Continuing care	Managing an efficient work place/office	4.12	1.85	45
Continuing care	Practicing cost effective health care	3.89	2.26	33
Development and behaviour	Learning disability, communicating with school regarding learning problems	4.00	2.43	31
Development and behaviour	Behaviour and conduct disorders	3.77	2.27	30
Mental health	Violent behaviour	3.47	2.01	29
Mental health	Anxiety disorders, phobias and obsessive compulsive disorders	3.54	2.17	28
Mental health	Depression	3.67	2.39	26
Mental health	Psychosomatic conditions	3.57	2.41	23
Acute care	Crisis resource management	4.03	2.92	22
Development and behaviour	Attention deficit disorders with or without hyperactivity	4.03	2.94	22
CNS and ophthalmology	Strabismus and vision assessment	3.57	2.46	22
Development and behaviour	Autism spectrum disorders, pervasive developmental disorders	3.84	2.81	21
Mental health	Attempted suicide	3.51	2.49	20
Acute care	Obtaining intravenous access in infants, children and youth	3.49	2.53	19
Cardiovascular	Interpreting ECGs (0–18 years)	3.74	2.88	17
Development and behaviour	Developmental delay, mental retardation, developmental regression	4.15	3.33	16
Continuing care	Assisting patients/parents in dealing with and navigating health care system	3.77	2.95	16
Continuing care	Performing practice-based improvement activities	3.88	3.07	16
Development and behaviour	Providing anticipatory guidance and well child/youth care	3.87	3.09	16
Acute care	Interpreting abdominal/chest X-rays and skeletal/ bone X-rays for fractures	3.90	3.16	15
GI and nutrition	Obesity	3.89	3.11	15
Development and behaviour	Assessing developmental milestones, psychomotor development	4.20	3.48	14
Acute care	Applying ethical principles to provision or withholding of clinical care, patient confidentiality and informed consent	4.13	3.40	14
Cardiovascular	Congenital heart disease, heart murmurs	4.11	3.41	14
Allergy and immunology	Allergy and immunology problems, drug/food allergy, anaphylaxis	4.00	3.29	14
ENT and respiratory	Hearing loss and hearing assessment	3.47	2.77	14
Mental health	Conducting a mental status examination	3.20	2.51	14
CNS and ophthalmology	Epilepsy, seizures	4.01	3.39	13
Dermatology	Acne, eczema and other dermatidites	3.95	3.32	13
CNS and ophthalmology	Floppy infant	3.89	3.25	13
Surgery, trauma and MSK	Non-life-threatening trauma, head trauma, fractures and burns	3.53	2.89	13
Renal and GU	Hypertension	3.70	3.11	12
Adolescent medicine	Risk taking (alcohol, drug, tobacco, and substance abuse), delinquency and sexually transmitted infections	3.66	3.07	12
Surgery, trauma and MSK	Gait disorders, joint and limb pain	3.56	2.94	12
Adolescent medicine	Contraception	3.27	2.66	12
Acute care	Endotracheal intubation in newborn, children and youth	3.84	3.29	11
Acute care	Provision of cardiopulmonary resuscitation in multidisciplinary teams and participation in mock codes in newborn, children and youth	3.86	3.33	11
Cardiovascular	Syncope, cardiac arrhythmias	3.64	3.08	11
Renal and GU	Menstrual cycle irregularities and menorrhagia	3.17	2.60	11
Acute care	Performing thoracentesis and chest tube placement	2.60	2.05	11