Most follicular cell-derived differentiated thyroid carcinomas are regarded as low-risk neoplasms prompting conservative therapeutic management. Here, we provide consensus recommendations reached by a multidisciplinary group of endocrinologists, medical oncologists, pathologists, radiation oncology specialists, a surgeon and a medication reimbursement specialist, addressing more challenging forms of this malignancy, focused on radioactive iodine (RAI)-resistant or -refractory differentiated thyroid carcinoma (RAIRTC). In this document we highlight clinical, radiographic, and molecular features providing the basis for these management plans. We distinguish differentiated thyroid cancers associated with more aggressive behavior from thyroid cancers manifesting as poorly differentiated and/or anaplastic carcinomas. Treatment algorithms based on risk-benefit assessments of different multimodal therapy approaches are also discussed. Given the scarcity of data supporting management of this rare yet aggressive disease entity, these consensus recommendations provide much needed guidance for multidisciplinary teams to optimally manage RAIRTC.

Context Indeterminate thyroid nodules (ITNs) lead to diagnostic surgeries in many countries. The use of molecular testing (MT) is endorsed by several guidelines, but costs are limitative, especially in public health care systems like in Canada. Objectives The primary objective of this work was to evaluate the clinical value of ThyroSeq v3 (TSv3) using benign call rate (BCR) in a real-world practice. The secondary objective was to assess the cost-effectiveness of MT. Methods This multicentric prospective study was conducted in 5 academic centers in Quebec, Canada. A total of 500 consecutive patients with Bethesda III (on 2 consecutive cytopathologies) or IV and TIRADS 3 or 4 nodules measuring 1 to 4 cm were included. MT was performed between November 2021 and November 2022. Patients with a positive TSv3 were referred for surgery. Patients with a negative TSv3 were planned for follow-up by ultrasonography for a minimum of 2 years. The BCR, corresponding to the proportion of ITNs with negative TSv3 results, was assessed. Results A total of 500 patients underwent TSv3 testing, with a BCR of 72.6% (95% CI, 68.5%-76.5%; P < .001). Ultimately, 99.7% of patients with a negative result avoided surgery. The positive predictive value of TSv3 was 68.2% (95% CI, 58.5%-76.9%). The cost-benefit analysis identified that the implementation of MT would yield a cost savings of $6.1 million over the next 10 years. Conclusion The use of MT (TSv3) in a well-selected population with ITNs led to a BCR of 72.6%. It is cost-effective and prevents unnecessary surgeries in a public health care setting.

Thyroid cancer management is rapidly changing. The identification of actionable biomarkers through both germline and somatic testing are now an integral part of directing patient management. However, deficiencies and disparities within existing thyroid cancer biomarker test approaches are resulting in inconsistent application for patient care. An expert panel was convened to create consensus biomarker testing algorithms and recommendations on actionable biomarker testing for patients diagnosed with medullary thyroid cancer, non-anaplastic follicular cell-derived thyroid cancer, or anaplastic follicular cell-derived thyroid cancer who may benefit from targeted therapies. A review of international guidelines was performed to determine the current state, and a literature review was carried out to further evaluate the evidence supporting the use of actionable biomarkers in patients diagnosed with thyroid cancer. Thyroid biomarker-related gaps impacting patient care were also discussed, with an emphasis on the importance of a multidisciplinary team approach for optimal patient care. The recommendations are presented with the aim to help physicians navigate the current thyroid cancer biomarker testing landscape with its many challenges, balancing aspirational care with what is practical and feasible in terms of economic realities and jurisdictional constraints. By remaining therapy-agnostic, these algorithms and recommendations are broadly applicable.

BackgroundDiabetic retinopathy (DR) affects about 25% of people with diabetes in Canada. Early detection of DR is essential for preventing vision loss. ObjectiveWe evaluated the real-world performance of an artificial intelligence (AI) system that analyzes fundus images for DR screening in a Quebec tertiary care center. MethodsWe prospectively recruited adult patients with diabetes at the Centre hospitalier de l’Université de Montréal (CHUM) in Montreal, Quebec, Canada. Patients underwent dual-pathway screening: first by the Computer Assisted Retinal Analysis (CARA) AI system (index test), then by standard ophthalmological examination (reference standard). We measured the AI system's sensitivity and specificity for detecting referable disease at the patient level, along with its performance for detecting any retinopathy and diabetic macular edema (DME) at the eye level, and potential cost savings. ResultsThis study included 115 patients. CARA demonstrated a sensitivity of 87.5% (95% CI 71.9-95.0) and specificity of 66.2% (95% CI 54.3-76.3) for detecting referable disease at the patient level. For any retinopathy detection at the eye level, CARA showed 88.2% sensitivity (95% CI 76.6-94.5) and 71.4% specificity (95% CI 63.7-78.1). For DME detection, CARA had 100% sensitivity (95% CI 64.6-100) and 81.9% specificity (95% CI 75.6-86.8). Potential yearly savings from implementing CARA at the CHUM were estimated at CAD $245,635 (US $177,643.23, as of July 26, 2024) considering 5000 patients with diabetes. ConclusionsOur study indicates that integrating a semiautomated AI system for DR screening demonstrates high sensitivity for detecting referable disease in a real-world setting. This system has the potential to improve screening efficiency and reduce costs at the CHUM, but more work is needed to validate it.

Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide.

Transformative changes in health professions education need to incorporate effective faculty development, but few very large-scale faculty development designs have been described. The Royal College of Physicians and Surgeons of Canada's Competence by Design project was launched to transform the delivery of postgraduate medical education in Canada using a competency-based model. In this paper we outline the goals, principles, and rationale of the Royal College's national strategy for faculty and resident development initiatives to support the implementation of Competence by Design. We describe the activities and resources for both faculty and trainees that facilitated the redesign of training programs for each specialty and subspecialty at the national level, as well as supporting the implementation of the redesign at the local level. This undertaking was not without its challenges: we thus reflect on those challenges, enablers, and the lessons learned, and discuss a continuous quality improvement approach that was taken to iteratively inform the implementation process moving forward.

Context: The SELECT trial led to the approval of lenvatinib for the treatment of advanced radioiodine-refractory differentiated thyroid carcinomas (DTCs) but also revealed an important adverse event (AE) profile which may limit its use in clinical practice. Objective: We aim to describe the efficacy and toxicity profiles of lenvatinib in real life. Methods: We included all patients who received lenvatinib for an advanced DTC at our institution, enrolling 27 patients. We reviewed retrospectively electronic medical records to assess efficacy and AEs. Results: Among the 24 patients with evaluation of tumor response during treatment, overall response rate (ORR) was 37.0% (95% CI, 19.4%576%), and disease control rate was 85.2% (95% CI, 66.3%-95.8%). The median progression-free survival (PFS) was 12 months (95% CI, 75-16.51. The most prevalent AEs were hypertension (778%), fatigue (55.6%), and weight loss (51.9%). At least one grade >= 3 AE was experienced by 25/27 patients (92.6%), mostly hypertension (59.3%). Lenvatinib was discontinued due to AEs in 13/27 patients (48.1%). Interestingly, 1 patient experienced a grade 4 posterior reversible encephalopathy syndrome, and another developed a Takotsubo cardiomyopathy. Conclusion: The safety profile of lenvatinib in our cohort was similar to that reported in the literature, with a predominance of hypertension. Rigorous blood pressure control is therefore essential to avoid discontinuing therapy. We also report 2 severe and rarely described AEs that physicians should watch for. As for efficacy, although less than in the SELECT trial, ORR and PFS were similar to other real-life studies.

Context: Université de Montréal medical school implemented Competency-based medical education, an important organizational change. Recognizing and reporting progress towards change is critical for success. Yet, informative frameworks that allow educators to track progress aren’t available. We used the Organizational Knowledge Creation Model for such a purpose. Purpose: This paper reports on how we used the Organizational Knowledge Creation Model to recognize change towards Competency-based Medical Education implementation. Method: Because Organizational Knowledge Creation Model focuses on the relationships between individuals and social structures, we selected an embedded case study approach. Diverse case sampling was used to select three academic departments: internal medicine, surgery and psychiatry. Data collection was conducted at two intervals, two years apart. Semi-structured interviews (individual and group) were conducted with Department Heads and Educators. Thematic analysis was conducted on the 15 interview transcripts and coded according to the four Organizational Knowledge Creation Model stages. Results: As implementation begins, selected and trained Educators critically revisit teaching routines and develop common conception of Competency-based medical education. This enables communication with wider audiences and intervene within existing working groups where Competency-based medical education is “broken down” into practical concepts. Educators’ roles evolved from “expert” who disseminates knowledge about Competency-based medical education, to responsive and pragmatic tutors who develop practical tools with peers and program directors. Conclusion: The Organizational Knowledge Creation Model framework provided a deep understanding of ongoing change. Study participants, interviewed twice, described their perception of change as it progressed as well as insights into the underlying dynamics. As medical schools evolve, Organizational Knowledge Creation Model may be a valuable conceptual tool to track progress and describe tangible changes.

Context: Competency-based medical education (CBME) implementation is being carried out in many medical schools worldwide. Academic Leadership is a strategy where selected Faculty act to influence peers to adopt change. The Universite de Montreal medical school, has adopted this strategy to implement CBME. Purpose: This paper aims to describe the work of Academic Leaders in the process of CBME implementation and to explore relevance of the Nonaka and Toyama organizational learning theory to map implementation progress. Method: Because knowledge creation model focuses on the relationships between leaders and social structures, embedded case study was selected. Diverse sampling method was used to select three departments: internal medicine, surgery and psychiatry, based on the number of CBME training activities. Data collection was at two intervals, two years apart. Semi-structured interviews (individual and group) were conducted with Department Heads and Academic Leaders. Thematic analysis was conducted on the 15 interview transcriptions.Results: As implementation begins, Leaders critically revisit accepted teaching routines and develop a common conception of CBME. This enables leaders to communicate with a wider audience and work within existing committees and working groups where they “break down” CBME into practical concepts. This practical understanding, disseminated through Entrustable Professional Activities, enables observable change. Conclusion: Leaders’ roles evolved from an “expert” that disseminates knowledge about CBME through lectures, to a responsive and pragmatic supporting role by developing and writing practical tools in collaboration with peers and program directors.

Context: Incidence of thyroid cancer is increasing, mostly because imaging studies are more performant. Most of these cancers do not recur and hemithyroidectomy can be sufficient. The aim of our study is to characterize patients who underwent hemithyroidectomy and follow their evolution.

Background Continuing professional development (CPD) activities are one way that new knowledge can be translated into changes in practice. However, few tools are available for evaluating the extent to which these activities change health professionals’ behavior. We developed a questionnaire called CPD-Reaction for assessing the impact of CPD activities on health professionals’ clinical behavioral intentions. We evaluated its responsiveness to change in behavioral intention and verified its acceptability among stakeholders. Methods and findings We enrolled 376 health professionals who completed CPD-Reaction before and immediately after attending a CPD activity. We contacted them three months later and asked them to self-report on any behavior change. We compared the mean rankings on each CPD-Reaction construct before and immediately after CPD activities. To estimate its predictive validity, we compared the median behavioral intention score (post-activity) of health professionals reporting a behavior change three months later with the median behavioral intention score of physicians who reported no change. We explored stakeholders’ views on CPD-Reaction in semi-structured interviews. Participants were mostly family physicians (62.2%), with an average of 19 years of clinical practice. Post-activity, we observed an increase in intention-related scores for all constructs (P < 0.001) with the most appreciable for the construct beliefs about capabilities. A total of 313 participants agreed to be contacted at follow up, and of these only 69 (22%) reported back. Of these, 43 (62%) self-reported a behavior change. We observed no statistically significant difference in intention between health professionals who later reported a behavior change and those who reported no change (P = 0.30). Overall, CPD stakeholders found the CPD-Reaction questionnaire of interest and suggested potential solutions to perceived barriers to its implementation. Conclusion The CPD-Reaction questionnaire seems responsive to change in behavioral intention. Although CPD stakeholders found it interesting, future implementation will require addressing barriers they identified.

Purpose Continually improving patient outcomes requires that physicians start new behaviors, stop old behaviors, or adjust how they practice medicine. Continuing professional development (CPD) is the method most commonly used by physicians to improve their knowledge and skills. However, despite regular physician attendance at these activities, change in clinical behavior is rarely observed. The authors sought to identify which of Bloom's domains (cognitive, affective, or psychomotor) are targeted by the learning objectives of CPD activities offered by medical associations, regulatory bodies, and academic institutions in the province of Quebec, Canada. Method The authors evaluated the objectives of 110 accredited CPD activities offered to physicians and other health professionals from November 2012 to March 2013. The objectives of each activity were extracted and classified into learning domains using Bloom's taxonomy. Results Ninety-six percent of the learning objectives analyzed targeted the cognitive domain, which consists of six levels of increasing complexity: knowledge, comprehension, application, analysis, synthesis, and evaluation. Half (47%) targeted knowledge and comprehension, whereas only 26% aimed to improve skills in analysis, synthesis, and evaluation. Conclusions Most accredited CPD activities within this sample were generally not designed to promote clinical behavior change because the focus of these activities was on remembering and understanding information instead of preparing physicians to put knowledge into practice by analyzing information, evaluating new evidence, and planning operations that lead to behavior change. Educators and CPD providers should take advantage of well-established theories of health professional behavior change, such as sociocognitive theories, to develop their activities.

BACKGROUND: In a previous phase 2 trial, axitinib was active and well tolerated in patients with advanced thyroid cancer. In this second phase 2 trial, the efficacy and safety of axitinib were evaluated further in this population, and pharmacokinetic/pharmacodynamic relationships and patient-reported outcomes were assessed. METHODS: Patients (N = 52) with metastatic or unresectable, locally advanced medullary or differentiated thyroid cancer that was refractory or not amenable to iodine-131 received a starting dose of axitinib 5 mg twice daily. The primary endpoint was the objective response rate (ORR). Secondary endpoints included progression-free survival (PFS), overall survival (OS), safety, pharmacokinetic parameters, and patient-reported outcomes assessed with the MD Anderson Symptom Inventory questionnaire. RESULTS: The overall ORR was 35% (18 partial responses), and 18 patients had stable disease for >= 16 weeks. The median PFS was 16.1 months, and the median OS was 27.2 months. All-causality, grade >= 3 adverse events (>5%) were fatigue, dyspnea, diarrhea, decreased weight, pain in extremity, hypertension, decreased appetite, palmar-plantar erythrodysesthesia, hypocalcemia, and myalgia. Patients who had greater axitinib exposure had a longer median PFS. Quality of life was maintained during treatment with axitinib, and no significant deterioration in symptoms or interference in daily life caused by symptoms, assessed on MD Anderson Symptom Inventory subscales, were observed. CONCLUSIONS: Axitinib has activity and a manageable safety profile while maintaining quality of life, and it represents an additional treatment option for patients with advanced thyroid cancer. (C) 2014 American Cancer Society.

Background: Medical education has traditionally been compartmentalized into basic and clinical sciences, with the latter being viewed as the skillful application of the former. Over time, the relevance of basic sciences has become defined by their role in supporting clinical problem solving rather than being, of themselves, a defining knowledge base of physicians. Methods: As part of the national Future of Medical Education in Canada (FMEC MD) project, a comprehensive empirical environmental scan identified the timing and integration of basic sciences as a key pressing issue for medical education. Using the literature review, key informant interviews, stakeholder meetings, and subsequent consultation forums from the FMEC project, this paper details the empirical basis for focusing on the role of basic science, the evidentiary foundations for current practices, and the implications for medical education. Findings: Despite a dearth of definitive relevant studies, opinions about how best to integrate the sciences remain strong. Resource allocation, political power, educational philosophy, and the shift from a knowledge-based to a problem-solving profession all influence the debate. There was little disagreement that both sciences are important, that many traditional models emphasized deep understanding of limited basic science disciplines at the expense of other relevant content such as social sciences, or that teaching the sciences contemporaneously rather than sequentially has theoretical and practical merit. Innovations in integrated curriculum design have occurred internationally. Less clear are the appropriate balance of the sciences, the best integration model, and solutions to the political and practical challenges of integrated curricula. Discussion: New curricula tend to emphasize integration, development of more diverse physician competencies, and preparation of physicians to adapt to evolving technology and patients’ expectations. Refocusing the basic/clinical dichotomy to a foundational/applied model may yield benefits in training widely competent future physicians.

CONTEXT Current debate in medical education focuses on the nature of 'competency-based medical education' (CBME) and whether or not it should be adopted. Many medical schools claim to run 'competency-based' curricula, but the structure of their programmes can differ radically. A review of the existing CBME literature reveals that little attention has been paid to defining the concept of competence. A straightforward examination of what is meant by the term 'competence' is noticeably missing from the literature, despite its impact on medical training.OBJECTIVES This paper aims to illustrate the varying conceptions of 'competence' by comparing and contrasting definitions provided in the health sciences education literature and discussing their respective impacts on medical education.METHODS A systematic review of recent publications in medical education journals published in English and French was conducted to extract definitions of competence or, if definitions were not explicitly stated, to derive the authors' implicit conception of competence. A sample of 14 definitions from articles in the health sciences education field was studied using thematic analysis. RESULTS There is agreement that competence is composed of knowledge, skills and other components. Although agreement about the nature of these other components is lacking, attitudes and values are suggested to be essential ingredients of competence. Furthermore, a clear divergence in conceptions of how a competent person utilises these components is apparent. One view specifies that competence involves selecting components according to specific situations, as required. A second view places greater emphasis on the synergy that results from the use of a combination of components in a given situation.CONCLUSIONS These conceptual distinctions have many implications for the way CBME is implemented. A conception of competence as the selection of components may lead to a greater emphasis, in a training setting, on the mastery of each component separately. A conception of competence as the use of a combination of components leads to greater emphasis on the synergy that results as they are deployed in clinical situations.

BACKGROUND:Continuing professional development (CPD) is one of the principal means by which health professionals (i.e. primary care physicians and specialists) maintain, improve, and broaden the knowledge and skills required for optimal patient care and safety. However, the lack of a widely accepted instrument to assess the impact of CPD activities on clinical practice thwarts researchers' comparisons of the effectiveness of CPD activities. Using an integrated model for the study of healthcare professionals' behaviour, our objective is to develop a theory-based, valid, reliable global instrument to assess the impact of accredited CPD activities on clinical practice.METHODS:Phase 1: We will analyze the instruments identified in a systematic review of factors influencing health professionals' behaviours using criteria that reflect the literature on measurement development and CPD decision makers' priorities. The outcome of this phase will be an inventory of instruments based on social cognitive theories. Phase 2: Working from this inventory, the most relevant instruments and their related items for assessing the concepts listed in the integrated model will be selected. Through an e-Delphi process, we will verify whether these instruments are acceptable, what aspects need revision, and whether important items are missing and should be added. The outcome of this phase will be a new global instrument integrating the most relevant tools to fit our integrated model of healthcare professionals' behaviour. Phase 3: Two data collections are planned: (1) a test-retest of the new instrument, including item analysis, to assess its reliability and (2) a study using the instrument before and after CPD activities with a randomly selected control group to explore the instrument's mere-measurement effect. Phase 4: We will conduct individual interviews and focus groups with key stakeholders to identify anticipated barriers and enablers for implementing the new instrument in CPD practice. Phase 5: Drawing on the results from the previous phases, we will use consensus-building methods to develop with the decision makers a plan to implement the new instrument.DISCUSSION:This project proposes to give stakeholders a theory-based global instrument to validly and reliably measure the impacts of CPD activities on clinical practice, thus laying the groundwork for more targeted and effective knowledge-translation interventions in the future.

Contexte/problématique : En Amérique, les formations avec simulation sont offertes principalement aux étudiants post gradués et sont rarement intégrées transversalement dans un cursus.Depuis 2004 nous avons développé un concept pédagogique innovateur en égard à la simulation.Nous offrons maintenant des formations avec et par simulation qui sont basées sur une approche poursuivant la performance 1 , les compétences 2 d'attitudes et d'habiletés, celles reliées à la gestion des risques et la sécurité des patients 3 et le travail d'équipe.Ceci nous permet de compléter l'apprentissage par problème ainsi que l'initiation à la médecine clinique et la démarche clinique auxquelles sont exposés nos étudiants des années précliniques.Des activités individuelles sont préalables à la venue en centre expérientiel avec ses entraînements avec simulation.Elles sont accompagnées de propositions pour permettre aux étudiants de poursuivre leur apprentissage selon un modèle développé pour l'aviation que nous souhaitons importer aussi pour les programmes de Développement Professionnel Continu (DPC) avec simulation et ceux des études post graduées.Objectifs/questions : Nous désirons soumettre notre approche pédagogique qui est originale en Amérique et dans la francophonie.Ces activités sont incluses, sur une base régulière et mensuelle, dans quatre années d'études des mille élèves inscrits à un doctorat en médecine dans nos deux 4 centres de simulation.Discussion/conclusion : Nous présentons une approche originale, systématique et intégrée au programme d'études médicales.

Contexte : En communauté française de Belgique, l'enseignement de la médecine est organisé en deux cursus.Le premier -baccalauréat -étudie l'homme normal.Le deuxième cursus -mastersétudie les pathologies avec, pour les 1 e et 2 e masters, une faible exploitation clinique.Les 3 e et 4 e masters bénéficient de pratiques cliniques hospitalières tout au long de l'année académique.Celles-ci sont réparties en dix mois de stages obligatoires dont un mois de gynécologie-obstétrique délimitant le cadre du projet pédagogique que nous travaillons avec les étudiants de 3 e master et avec les assistants-pilotes qui les accompagnent.Problématique : Bien que les étudiants de 1 e master reçoivent dix heures d'un cours de psychologie médicale assorti de douze heures de « travaux pratiques », les assistants-pilotes observent de profonds malaises chez les stagiaires de 3 e master.Ainsi, posons nous la question de l'acquisition et de la mobilisation de la compétence professionnelle « communication clinique » lors du parcours clinique de gynécologie-obstétrique. Finalité : Mobilisation, progression, co-évaluation et régulation de cette compétence.Dispositif : Deux familles de situations sont définies afin de mieux cerner l'appropriation de cette compétence professionnelle dans le cadre des stages.La première s'intitule « Lors d'une consultation de base.».La deuxième s'intitule « Lors d'une consultation incluant une annonce difficile.».Dès le début du stage, nous proposons aux étudiants une grille fondée sur la première famille de situations.À dessein non certificatif, cet outil intègre les paramètres à évaluer et leurs indicateurs de développement.Lorsque l'étudiant en fait la demande, son auto-évaluation est discutée avec l'assistant-pilote.Au terme du parcours, suite à l'organisation d'un atelier encadré par un médecin formé à la communication clinique (jeux de rôle et exercices de simulation) intitulé « Lors d'une consultation de base.», l'étudiant évalue sa compétence avant et après la formation.S'ensuit une confrontation des jugements et une prise de conscience par l'étudiant de son niveau de développement.La deuxième famille de situations est abordée à mi-parcours lors d'un atelier intitulé « Lors d'une consultation incluant une annonce difficile.».L'analyse de cas vécus par les apprenants, la métacognition, la conceptualisation (carte conceptuelle), l'évaluation et la régulation sont organisées et gérées grâce à l'intervention d'un psychologue clinicien.Impacts anticipés : Ce processus devrait faciliter la régulation des activités mentales ainsi qu'une anticipation adéquate de la communication clinique avec les patientes dans ces deux familles de situations.Dans l'avenir, si les résultats de cette recherche-action s'avèrent positifs, la faculté propose d'installer cette pratique dans d'autres départements cliniques.Les résultats seront évalués à l'aide de focus-groups avec les stagiaires afin d'évaluer leurs perceptions de l'aspect formatif des ateliers.