Accreditation systems create and enforce the rules for medical education. When accreditors expand their scope or change their standards or protocols, every medical school they regulate must change, with lasting impacts on large numbers of graduating physicians. Because accreditation of undergraduate medical education (UME) has become globally accepted and widespread, one may assume it is supported by strong evidence. Such is not the case. This article recounts the origins of accreditation in the U.S. over 100 years ago as an effort to distinguish allopathic physicians from their competitors. It describes how the U.S. model for UME accreditation formed the basis for approaches endorsed by global organizations, and accreditation expanded without research demonstrating that a specific combination of standards, self-studies, and site visits was optimal or necessary. Allowing assumptions about accreditation to go unchecked can create problems, such as misalignment of accreditation systems with needs, wasted resources, and lack of trust. Accreditation science - systematic inquiry that directly interrogates and informs accreditation policies and practices – offers a way to test assumptions and generate evidence that leads to reform. Authors provide examples of accreditation science from around the world over the last three decades. They describe resources that can be used for accreditation science and models that could allow more of the global medical education community to participate. They also suggest priority areas of investigation, such as how accreditation judgments are made and the economics of accreditation and international accreditor marketplaces. The scientific method has for centuries proven to be the most efficient way to generate knowledge that improves the lives of people. It is past time for accreditation to move from its longstanding basis in tradition and assumption into an era defined by scientific inquiry.

Forceps Assisted Vaginal Delivery (FAVD) commonly relies on mannequin-based simulators that provide valuable anatomical rehearsal; however, integrated quantitative assessment is often limited to instructor observation and debriefing, or to partial objective measures (e.g., force/event logging) rather than detailed forceps kinematics (e.g., trajectory and end pose). Studies indicate a lack the competency to perform the procedure independently, thus leading to an increase in unnecessary cesarean sections, which have immediate negative impacts on maternal, neonatal, and child health. We present the development of an extended reality (XR) FAVD simulator integrating a forceps-compatible 3D printed user interface with virtual feedback for instructional support and performance assessment. We report a preliminary formative evaluation for usability, cognitive load, and performance metrics among two obstetrics instructors. Although this study did not include a comparative control condition (e.g., standard mannequin-only training), the exploratory nature of the collected data provided insights into the design and face validity of the prototype and not training efficacy at this stage. This work contributes a novel XR training system and insights for integrating tangible interaction, performance sensing, and feedback in high-stakes skill training. Beyond obstetrics, this work illustrates how tangible tool integration, spatial alignment, and embedded motion-based feedback can be combined in XR systems to support skill development leveraging 3D printing and open electronics.

In Canada, additional training in Transfusion Medicine (TM) can be pursued through Area of Focused Competence (AFC) Diploma programs. The Transfusion Medicine AFC program was one of the first in Canada to adopt a competence by design philosophy through a portfolio. This objective of this study was to evaluate the TM AFC assessment portfolio and its impact on interest-holders. A realist framework was used to explore the outcomes of the competency portfolio, and the contexts and mechanisms involved. Purposive sampling was used to recruit participants trainees, teachers, and curriculum developers from across the country. Qualitative data was collected from 22 participants through semi-structured interviews. Data was coded and used to refine initial program theories. Key outcomes were identified such as increased trainee confidence and knowledge, recognition of specialist knowledge, and a sense of community within the transfusion medicine field. Data analysis revealed mechanisms that enabled these outcomes within the contexts of academic care centres and Canadian blood suppliers. This realist evaluation highlighted the positive outcomes of the TM AFC competency-based portfolio and provided a modified program theory that reveals how the portfolio impacts learners.

Background: Access to trauma-focused mental health care is often limited by shortages of specialized HCPs, high training costs, and resource constraints. Research on the real-world implementation of scalable training and intervention models remains limited.Objective: To evaluate the implementation of the Community Access to Resourced & Resilient PsychoEducation (CARE) intervention across healthcare organizations in Ontario, Canada, using an implementation science framework.Methods: This prospective, mixed-methods implementation study used Proctor's Implementation Outcomes Framework to assess the CARE intervention across five healthcare organizations from February 2022 to October 2023. CARE includes asynchronous healthcare HCP training, delivery of an 8-week trauma-focused psychoeducation and skill-building group, and weekly virtual supervision for group facilitators. Feasibility, acceptability, and sustainability were assessed using recruitment and adherence data, post-group interviews with HCPs (n = 15) and supervisors (n = 7), post-intervention acceptability questionnaires, and follow-up surveys with participating sites at 6 and 12 months. Pre- and post-intervention measures of PTSD symptoms (PCL-5) and depression, anxiety, and stress (DASS-21) were compared using paired t-tests.Results: All five sites successfully implemented the intervention, demonstrating high feasibility and acceptability. Forty-eight multidisciplinary HCPs completed training, 24 co-facilitated at least one therapy group. Thematic analysis of interviews highlighted positive learning experiences and skill development. Adult patients (N = 163; mean age 46; 84.0% female) with a history of trauma prior to age 18, were enrolled in the study, with 64.4% attending at least 6 of 8 group sessions. Significant reductions in PTSD symptoms were observed post-intervention (d = 0.49) alongside improvements in depression (d = 0.36), anxiety (d = 0.40), and stress (d = 0.39). All sites sustained the implementation of the intervention at one-year follow-up.Conclusion: The successful implementation of the CARE intervention across diverse healthcare settings underscores its scalability and promise as an accessible model for delivering trauma-focused care.

As medical schools rapidly expand worldwide, accreditation has become a key mechanism for ensuring and improving the quality of medical education. However, its effectiveness remains unclear due to conflicting research results and limited empirical evidence. Therefore, the aim of this critical narrative review is to synthesize and analyze the intended (planned) and unintended (emergent) impacts of medical school accreditation. We conducted a critical narrative review by systematically searching five databases: MEDLINE, EMBASE, ERIC, Global Index Medicus, and ProQuest. The literature search was conducted between October and November 2024. Thirty-two empirical studies on the impact of medical school accreditation were included. Following a subjectivist orientation, we combined deductive categorization and inductive thematic analysis for analysis. Three researchers conducted repeated coding and data extraction through a consensus process, identifying both planned and emergent processes and outcomes. The planned processes included governance reform, faculty and student engagement, infrastructure investment, data monitoring and sharing, structured curriculum reform, and the introduction of program evaluation of quality improvement systems. These contributed to improved student outcome, curriculum refinement, and enhanced institutional awareness. However, emergent processes were identified, such as navigating conflicting demands, strategically controlling data disclosure, and adapting to changes in standards. These led to emotional ambivalence among stakeholders, resources intensification, and short-term strategizing that hindered sustainable reform. These results challenge the assumption that accreditation operates linearly, emphasizing that its impact on medical schools is accompanied by both intended and unintended effects. Policymakers and institutions must recognize the dual nature of accreditation, promote sustainable engagement, and proactively address unexpected outcomes to ensure that accreditation aligns well with long-term educational goals.

The World Health Organization (WHO) defined 'social accountability for medical schools' in 1995; yet 30 years later, many remain concerned that medical schools are not living up to societal expectations. In this article, we first place the WHO's definition into historical context, then we contrast the WHO social 'contract', where schools are expected to demonstrate value for money, with the more altruistic 'code' that had been put forward previously by Abraham Flexner. We discuss contemporary barriers to advancing social accountability, including tacit assumptions about the semantics of the term accountability, the geographic communities schools should serve, how schools are financed, and expectations for school outcomes. We suggest that the future of social accountability for medical schools movesbeyond social codes and contracts to recognizing the varied ways that medical schools contribute to diverse individuals and groups within communities along a local to global spectrum. While it is unlikely that there will be universal consensus on what makes a medical school valuable to those whom it impacts, medical schools should make data available that allow others to render their own judgments and participate in conversations that help medical schools and medical education systems better align resources with needs.

The long-term effects of adverse childhood experiences, including various forms of abuse, neglect, and trauma, are well-documented but often inadequately addressed in healthcare settings. Healthcare providers frequently lack the training necessary to provide trauma-focused, evidence-based interventions. To address this gap, we developed the ‘Community Access to Resourced Resilient PsychoEducation’ (CARE) training program, a scalable, asynchronous, virtual learning platform designed to equip healthcare providers with the skills and knowledge to facilitate an 8-week trauma-focused psychoeducational group intervention for adults with a history of childhood interpersonal trauma. In this cross-sectional study, we evaluated the feasibility, usability, and acceptability of the CARE training program among 62 healthcare providers from six organizations across Ontario. Pre- and post-training questionnaires were used to assess these domains using a combination of Likert-scale items and open-ended questions. Sixty-two healthcare providers from six Ontario organizations enrolled in the CARE training program; 42

Forceps-assisted vaginal delivery simulation relies on traditional instruction following the Halstedian teaching model using advanced simulators that require specialized infrastructure and upkeep. With reduced hands-on training caused by a lack of cost-effective simulators, a current trend in newborn deliveries is seen an increasing preference for C-sections, which carry higher health risks and a more difficult recovery. Although C-sections are important, skills for assisted forceps delivery are equally relevant, in particular as trainees are required to develop spatial awareness for inserting, securing, and delivering the baby. Our paper presents work-in-progress prototyping a low-cost mixed reality (MR) forceps-assisted vaginal delivery simulator using 3D printing and open electronics.

Background:Many adults with posttraumatic stress disorder (PTSD) related to childhood interpersonal trauma (CIT) face substantial barriers to care and limited access to trauma-specific treatment. We evaluated the efficacy of the Trauma PORTAL (Providing Online tRauma Therapy using an Asynchronous Learning platform), a trauma-focused hybrid therapy integrating self-paced psychoeducational and skills-based modules and virtual therapist-led group sessions, to reduce PTSD symptoms in adults with a history of CIT. Methods:This randomised, assessor-masked, controlled, parallel-group trial was conducted at a single site in Ontario, Canada. Participants (≥18 years) with a history of CIT were recruited within an ambulatory urban hospital and met criteria for PTSD based on the Mini-International Neuropsychiatric Interview (MINI). Participants were randomly assigned (1:1) to Trauma PORTAL (intervention; eight online modules and eight optional weekly 1-h virtual group sessions facilitated by two trauma therapists) or treatment as usual (control). The primary outcome was severity of PTSD symptoms assessed at 8 weeks relative to baseline, measured by self-report on the PTSD Checklist for DSM-5 (PCL-5). Outcomes were analysed in the intention-to-treat population using a linear mixed-effects model. Secondary outcomes included clinician-rated PTSD severity using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), emotion regulation, depression, anxiety, stress, and self-compassion. Individuals with lived experience of CIT were involved in the development of the Trauma PORTAL intervention, but not in the design of this trial. The trial was registered with ClinicalTrials.gov (NCT05670405). Findings:Between November 7, 2022, and October 6, 2023, 328 participants were screened for eligibility, and of these 183 (56%) provided consent and were enrolled. After 2 were lost to follow-up, 181 participants were randomly assigned to Trauma PORTAL (91 [50%]) or control (90 [50%]). At baseline, 147 (81%) participants were women, mean age was 40.8 years (SD 11.5), and 119 (66%) were White. Trauma PORTAL was superior to control in reducing PTSD symptoms, showing an adjusted mean difference (aMD) on the PCL-5 at week 8 of -7.08 (95% CI -11.55 to -2.61), corresponding to a moderate effect size (d = 0.44 [95% CI 0.12-0.76]). This effect was maintained at week 16 (aMD -7.00, 95% CI -11.83 to -2.18). No adverse events were reported. Interpretation:Trauma PORTAL reduced PTSD symptoms more than treatment as usual, supporting its potential as an effective and acceptable hybrid psychoeducation and skills-based therapy that may help expand access to trauma-focused care for adults with CIT. Further evaluation against established treatments is warranted. Funding:This project was supported by the WCHAMSG (Women's College Hospital Alternative Medical Staff Group) Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario, and the Department of Psychiatry, Women's College Hospital.

The COVID-19 pandemic triggered a global pivot to virtual care (VC) technologies. While there has been considerable academic work exploring the “how” of VC, few studies have explored the impact of this pivot, its unintended consequences, and its governing rationales. This study addresses this gap in relation to care, professional identity and the evolving requirements for health professions education. Collected over three years, data for this study included evaluation surveys (134), interviews (59), publicly-available documents (240), and academic articles (217). Interviews and surveys were conducted in the Toronto Academic Health Science Network (TAHSN) and in a European academic medical centre (Maastricht UMC). Criteria for academic literature were that they addressed the shift to VC and were published between 2019 and 2023. Foucault’s work, The Birth of the Clinic, his methodologies of Critical Discourse Analysis and his concept of spatiality, guided the analysis. Patients, clinicians and institutional leaders were appreciative of VC and the perceived improvements brought to care logistics, patient experience and efficiencies. Two discourses governed these sentiments—VC as a tool for both “service” and “managerialism.” Assessing changes in clinical practice, experience and professional identity, our analysis suggested that a new virtual clinical space was being produced, one in which rules and experiences were different from that of a classical clinic. We named this new space the “Mediverse”—a space of undiscovered complexity with material and unintended consequences on user experience. This study identifies a new framework in which to study and assess this new clinical space.

Recent advances in immersive technologies have facilitated the development of highly realistic and cost-effective computer-based simulations (CBS) and this has greatly influenced health professions training. Unlike high-end simulators that require specialized devices, keyboards, mice, gamepads, virtual reality (VR) controllers, and 3D-printed custom interfaces facilitate interactions with CBSs. However, given the lack of proper task representation, many questions remain regarding their effects on the user experience. This paper presents usability, cognitive load and presence preliminary study comparing a virtual laparoscope manipulation using a keyboard and mouse, gamepad, VR controllers and a 3D-printed laparoscopic controller.

BACKGROUND:The long-term mental and physical health implications of childhood interpersonal trauma on adult survivors is immense, however, there is a lack of available trauma-focused treatment services that are widely accessible. This study, utilizing a user-centered design process, sought feedback on the initial design and development of a novel, self-paced psychoeducation and skills-based treatment intervention for this population. AIMS:To explore the views and perspectives of adult survivors of childhood interpersonal trauma on the first two modules of an asynchronous trauma-focused treatment program. METHODS:Fourteen participants from our outpatient hospital service who completed the modules consented to provide feedback on their user experience. A thematic analysis of the three focus groups was conducted. RESULTS:Four major themes emerged from the focus groups: (1) technology utilization, (2) module content, (3) asynchronous delivery, and (4) opportunity for interactivity. Participants noted the convenience of the platform and the use of multimedia content to increase engagement and did not find the modules to be emotionally overwhelming. CONCLUSIONS:Our research findings suggest that an asynchronous virtual intervention for childhood interpersonal trauma survivors may be a safe and acceptable way to provide a stabilization-focused intervention on a wider scale.

Background:Adults with mental health symptoms stemming from childhood interpersonal trauma require specialized trauma-focused psychological interventions. Limitations in accessing treatment interventions for this population necessitate innovative solutions. This study explored the feasibility of a protocol for a blended e-health psychoeducational treatment intervention for this population called the Trauma PORTAL (Providing Online tRauma Therapy using an Asynchronous Learning platform), combining asynchronous online modules and weekly live virtual group sessions. Method:From October 2021 to February 2022, this prospective, single-arm study recruited participants who were waitlisted for trauma therapy at an academic hospital. The primary outcome was protocol feasibility, including recruitment, adoption, and intervention acceptability. Secondary outcomes were pre- and post-intervention post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for DSM-5 [PCL-5]), depression/anxiety/stress (Depression and Anxiety Stress Scale [DASS-21]), and emotion regulation (Difficulties in Emotion Regulation Scale [DERS-18]), which were compared using paired t-tests and presented as mean differences (MDs) and 95% confidence intervals (CIs). Results:A total of 66 participants (median age = 37, female = 61) were enrolled, and they completed on average 53.5% of the online modules. There were 51 (77%) participants who completed post-intervention questionnaires. Acceptability was very high, with 49 respondents (98%) reporting that the intervention increased their access to health care. There were reductions from pre- to post-intervention on the PCL-5 (49.1 vs. 36.7, MD -12.4, 95% CI 8.3-16.5), DERS-18 (51.8 vs. 48.8, MD -3.3, 95% CI 0.2-6.4), and DASS-21 (60.1 vs. 50.7, MD -9.4, 95% CI 2.3-16.6). Conclusion:The Trauma PORTAL intervention was feasible to implement, well-adopted, and highly acceptable in an ambulatory trauma therapy program. The findings show promising evidence for symptom reduction. Further evaluation of the Trauma PORTAL's efficacy in a randomized trial is warranted.

INTRODUCTION:Although programme evaluation is increasingly routinised across the academic health sciences, there is scant research on the factors that shape the scope and quality of evaluation work in health professions education. Our research addresses this gap, by studying how the context in which evaluation is practised influences the type of evaluation that can be conducted. Focusing on the context of accreditation, we critically examine the types of paradoxical tensions that surface as evaluation-leads consider evaluation ideals or best practices in relation to contextual demands associated with accreditation seeking.METHODS:Our methods were qualitative and situated within a critical realist paradigm. Study participants were 29 individuals with roles requiring responsibility and oversight on evaluation work. They worked across 4 regions, within 26 academic health science institutions. Data were collected using semi-structured interviews and analysed using framework and matrix analyses.RESULTS:We identified three overarching themes: (i) absence of collective coherence about evaluation practice, (ii) disempowerment of expertise and (iii) tensions as routine practice. Examples of these latter tensions in evaluation work included (i) resourcing accreditation versus resourcing robust evaluation strategy (performing paradox), (ii) evaluation designs to secure accreditation versus design to spur renewal and transformation (performing-learning paradox) and (iii) public dissemination of evaluation findings versus restricted or selective access (publicising paradox). Sub-themes and illustrative data are presented.DISCUSSION:Our study demonstrates how the high-stakes context of accreditation seeking surfaces tensions that can risk the quality and credibility of evaluation practices. To mitigate these risks, those who commission or execute evaluation work must be able to identify and reconcile these tensions. We propose strategies that may help optimise the quality of evaluation work alongside accreditation-seeking efforts. Critically, our research highlights the limitations of continually positioning evaluation purely as a method versus as a socio-technical practice that is highly vulnerable to contextual influences.

The shortage of adequately trained healthcare providers (HCPs) able to treat adults who have experienced childhood interpersonal trauma (CIT) is a pressing concern. This study explored HCPs' training needs for a trauma-focused psychoeducational group intervention and the potential barriers and facilitators to accessing such training. Three 1-hour focus group sessions were conducted with HCPs (n = 17) from two urban and one rural community healthcare organization serving diverse populations in Ontario, Canada, including under-housed people, women struggling with mental health and addiction, and LGBTQ+ populations. On average, participants had 2.4 years in their current role and 18.1 years of mental health field experience. Thematic analysis revealed key findings: a strong clinical need for trauma services, accessible training programs, and broadly applicable interventions relevant for diverse populations. Notably, participants emphasized the clinical advantages and increased accessibility of a virtual training programs focused on psychoeducational treatment interventions, particularly within community-based healthcare settings. This study highlights the potential of a virtual psychoeducational training programs for HCPs to address this critical gap in healthcare provision for individual with CIT. It also underscores the need to move beyond training program development and focus on implementation and sustainability of interventions in clinical practice.

Background: The COVID-19 pandemic profoundly impacted medical education systems worldwide. Between March 2020 and December 2021, 111 MD students at the University of Toronto completed two-week quarantines due to hospital or community exposures and experienced disrupted clinical instruction. We explored the experiences, barriers, and supports of these quarantined medical students to identify program development opportunities and improve student supports. Methods: We used a qualitative descriptive approach to explore experiences of clerkship students quarantined due to COVID-19 exposure. Methods included an online survey with open-ended questions and an audio-recorded interview. We analysed the demographic survey responses using descriptive statistics. Subsequently, we conducted descriptive thematic analysis of the narrative survey responses and transcribed interview recordings. Results: Concerns reported in surveys (n = 23, response rate 20.7%) and interviews (n = 5) included themes of illness uncertainty, racial tensions, confidentiality of COVID-19 status, unclear academic expectations, and financial burden. Supports included friends, family, and MD program administration. Recommendations related to communication, administration, equity considerations, supports, confidentiality/privacy, and academics. Conclusion: Supporting student wellbeing and learning is at the core of medical training. Enhanced understanding of health profession trainee needs during COVID can improve institutional supportive responses to students routinely and during times of crisis.

Key pointsWhat's already known about this topic? Twin to twin syndrome (TTTS) is a serious complication of monochorionic twin pregnancy The treatment of choice is fetoscopic laser ablation of placental anastamoses Simulation plays an important role in teaching this high‐acuity procedure What does this study add? We report the development of a high‐fidelity digital simulation system for teaching TTTS fetoscopic lasers Remote teaching has been demonstrated to work well with this system This simulator is robust, easy to store and assemble and relatively inexpensive.

INTRODUCTION:The COVID-19 pandemic had significant impacts on many aspects of health care and education, including the accreditation of medical education programmes. As a community of international educators, it is important that we study changes that resulted from the pandemic to help us understand educational processes more broadly. As COVID-19 unfolded in Canada, a revised format of undergraduate medical accreditation was implemented, including a shift to virtual site visits, a two-stage visit schedule, a focused approach to reviewing standards and the addition of a field secretary to the visit team. Our case study research aimed to evaluate the sociomaterial implications of these changes in format on the process of accreditation at two schools.METHODS:We interviewed key informants to understand the impacts, strengths and limitations of changes made to the accreditation format. We used an abductive approach to analyse transcripts and applied a sociomaterial lens in looking for interconnections between the material and social changes that were experienced within the accreditation system.RESULTS:Stakeholders within the accreditation system did not anticipate that changes to the accreditation format would have significant impacts on how accreditation functioned or on its overall outcomes. However, key informants described how the revised format of accreditation reconstructed how power was distributed and how knowledge was produced. The revised format contributed to changes in who held power within each of the programmes, within each of the visiting teams and between site members and visiting team members. As power shifted across stakeholders in response to material changes to the accreditation format, key informants described changes in how knowledge was produced.CONCLUSIONS:Our findings suggest that the most powerful knowledge about any given programme might best be obtained through individualised tools, technologies and voices that are most meaningful to the unique context of each programme. Deliberate attention to how knowledge and power are influenced by the interactions between material and social processes within accreditation may help educators and leaders see the effects of change.