OBJECTIVES:Recent policy proposals call for formal integration of clinical reasoning into medical education competency frameworks. We describe how these proposals represent and problematize clinical reasoning, and what they allow health professionals subject to them to say, do, and be in their teaching, assessment and practice of clinical reasoning. METHODS:Using Carol Bacchi's "What is the problem represented to be?" approach, we conducted a discourse analysis comparing two policy proposals calling for integration of clinical reasoning into competency frameworks in Canada and the United States. RESULTS:In the policy proposals, the problem of clinical reasoning is represented as: (1) an educational problem, characterized by poor teaching and assessment, and (2) as a problem of medical error, with poor clinical reasoning described as a source of errors. By calling to policy changes in individual competency frameworks, these policy proposals could codify clinical reasoning as an issue of individual competency, focusing research, teaching, and assessment at this level, rather than as a situated, relational, or collective competence. This problem representation constrains pluralistic forms of understanding clinical reasoning that view it as arising from interactions between patients, healthcare teams, and care contexts. CONCLUSIONS/IMPLICATIONS:Representing clinical reasoning as an individual problem that requires educational intervention centers physicians as decision-makers and responsible for the outcomes of clinical reasoning. This silences the voices of patients and other health professions while elevating the role of education to resolve the problem of clinical reasoning and absolving health systems of their responsibility in mitigating error.

BACKGROUND:Despite calls from various global organizations for increased attention to global surgery, guidance on developing effective curricula is lacking. In this scoping review, we aimed to outline the necessary learning objectives and competencies for establishing sustainable, equitable, and noncolonialist academic global surgery programs. METHODS:This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews. We used key terms to search 5 electronic databases and conducted a comprehensive grey literature search to identify universities, medical programs, and organizations offering academic global surgery programs. We categorized curricular objectives extracted from these sources into the 11 domains of global health defined by the Consortium of Universities on Global Health. We employed thematic analysis to further categorize these objectives into unique themes within each domain. RESULTS:We found a total of 43 studies and 61 programs through database and grey literature searches, respectively. These sources yielded 333 unique curricular objectives, which we analyzed thematically, revealing 41 unique themes spanning various neglected areas in global surgery, such as Indigenous health, environments, chronic diseases, technology, and underserved populations like refugees, urban populations of low socioeconomic status, and racial and ethnic minority groups. CONCLUSION:This review outlines essential skills for effective engagement in modern global surgical care, emphasizing the emergence of nontraditional themes like bidirectional partnerships, sustainability, and self-governance over mission-based approaches. Integrating these forward-looking themes into global surgery curricula is vital for improving global surgical care standards and fostering a skilled, globally aware workforce.

The transition to independent surgical practice presents substantial challenges for new-to-practice surgeons. Intraoperative teaching is particularly difficult, given that clinical demands can conflict with educational responsibilities. Limited guidance exists regarding how to balance these dual roles. To address this gap, we explore how new-to-practice surgeons manage the positions of attending surgeon and surgical educator in the operating room (OR). In this constructivist grounded theory study, we conducted semi-structured interviews with ten new surgeons from seven specialties in British Columbia, Canada who regularly taught in the OR. Data collection and analysis were iterative, using constant comparison to inform theoretical sampling, the interview guide, and thematic analysis of the data until sufficiency was reached. Coding was supported by team discussions, memo-writing, and diagramming, and reflexivity was maintained through journaling. Three themes were identified through our analysis: (1) the inherent challenge of balancing the dual roles of attending surgeon and surgical educator, (2) the informal strategies participants used to manage this balancing act (anticipating, monitoring, recruiting, and compensating), and (3) the ongoing need to develop participants’ capacity to balance both roles effectively. This study highlights the challenges new surgeons face in balancing clinical and teaching responsibilities, and the underappreciated effort required to ‘balance’ these dual roles. Our findings suggest that developing proficiency as both the attending surgeon and surgical educator in the operating room is a gradual developmental process—one that would benefit from deliberate support during surgical training and in the early stages of a surgical career.

PURPOSEThe global burden of cancer is growing rapidly, with a disproportionately higher increase in low- and middle-income countries. West Africa is particularly affected by this rise, where cancer control systems are woefully inadequate to meet the increasing needs of patients. Although many gaps exist across the continuum of cancer care, perhaps the most striking is the lack of surgical services, which plays a vital role in up to 80% of all patients with cancer. To address this critical gap in cancer care, the West African College of Surgeons established a bilateral partnership with Queen's University, Canada, to grow the surgical oncology workforce for the region by cocreating and implementing a general surgical oncology fellowship training program.METHODSTo inform the design of the curriculum tailored to the cancer care needs of West Africa, a narrative review of the literature was performed to identify the incidence and mortality associated with general surgical cancers in the region, as well as the health care resources available to address these malignancies.RESULTSThis comprehensive report provides a contemporary understanding of the landscape of cancer care with respect to the burden of disease, the existing resources, and the challenges in delivery of cancer services for West Africa.CONCLUSIONThe findings in this report quantify the unmet demand for cancer care in West Africa and highlight the scope for context-specific cancer training in this region.

OBJECTIVE:This project aimed to achieve international consensus on core learning objectives for global surgery education. BACKGROUND:As global surgery emerges as an academic field, there is a growing need for consensus-driven learning objectives to guide education and training. Existing curricula vary widely and lack multidisciplinary input. METHODS:A modified Delphi consensus was conducted with an international panel of global surgery experts. A scoping review informed an initial list of learning objectives, categorized into 14 domains based on the Consortium of Universities for Global Health framework. Panelists rated objectives over three iterative survey rounds, with consensus defined as ≥80% agreement within ±1 Likert point of the median. RESULTS:Sixty-one experts from 26 countries across all World Health Organization (WHO) regions participated, representing surgery (40.1%), anesthesia (14.8%), obstetrics and gynecology (14.8%), general practitioners with and without enhanced surgical skills (16.4%), and allied health fields (6.6%). The majority (57.4%) had over 10 years of experience in global surgery. Across three Delphi rounds, 120 learning objectives reached consensus, covering key domains such as the global burden of surgical disease, surgical system strengthening, ethics and equity, health policy, and sustainable development. A total of 25 (20.8%) objectives were designated for introductory learners, 55 (45.8%) for advanced learners, and 40 (33.3%) for both levels. CONCLUSION:This Delphi consensus provides a structured, globally relevant framework for global surgery education, supporting curriculum development and competency-based training. These findings underscore the importance of aligning global surgery education with evolving healthcare priorities while ensuring adaptability across diverse surgical contexts.

OBJECTIVE:The objective was to identify clinical and radiological factors associated with sleep-disordered breathing (SDB) in children with Chiari type I malformation (CIM) and to evaluate the efficacy of foramen magnum decompression (FMD) in resolving SDB. METHODS:A retrospective chart review was conducted for all children evaluated for CIM at a single institution from 2002 to 2022, identifying all children who had undergone nocturnal polysomnography (PSG). Apnea-hypopnea index (AHI) score, sleep apnea type (obstructive, central, mixed, and unspecified), clinical manifestations, and radiological measurements were recorded. SDB was considered present when officially diagnosed in the PSG report. Logistic regression was performed to identify factors correlating with the presence of SDB. For children with SDB who underwent FMD, the Wilcoxon signed-rank test was used to assess AHI improvement. RESULTS:Of the 997 children referred for CIM, 310 completed PSG. SDB was diagnosed in 147 patients (overall prevalence 14.7%, 95% CI 12.7%-17.1%; prevalence among children with PSG 47.4%, 95% CI 41.9%-53%). Specific SDB diagnosis consisted of 33% of patients with central sleep apnea, 27% with obstructive sleep apnea, 9% mixed, and 31% unspecified. Lower cranial nerve (CN) dysfunction (OR 3.891, p = 0.009), tonsillar position (OR 1.049, p = 0.017), Chiari type 1.5 malformation (OR 1.862, p = 0.044), and BMI (OR 1.039, p = 0.036) were significantly associated with presence of SDB. Of the 310 patients who underwent PSG, 47 were originally categorized as asymptomatic: 27 (57%) of these asymptomatic patients were diagnosed with SDB on PSG. Of children diagnosed with SDB, 34 completed PSG before and after FMD. Median AHI score decreased from 6.5 preoperatively to 1.8 postoperatively, with a median (IQR) difference of -2.3 (-11.9 to 0.1) (p = 0.001). Twelve (35%) had resolution of SDB. CONCLUSIONS:The authors' findings suggest that the prevalence of SDB in children with CIM is high (15%-47%). Furthermore, lower CN dysfunction, Chiari type 1.5, lower tonsillar position, and higher BMI may be risk factors. Notably, SDB can be present even in the absence of clinical symptoms. This study also demonstrates that surgical intervention has the potential to reduce the severity of SDB. These results could help clinicians identify CIM patients at risk for SDB and those who may benefit from surgical decompression.

Point-of-care ultrasound (POCUS) allows for rapid bedside assessment and guidance of patient care. Recently, POCUS was included as a mandatory component of Canadian anesthesiology training; however, there is no national consensus regarding the competencies to guide curriculum development. We therefore aimed to define national residency competencies for basic perioperative POCUS proficiency. We adopted a Delphi process to delineate relevant POCUS competencies whereby we circulated an online survey to academic anesthesiologists identified as POCUS leads/experts (n = 25) at all 17 Canadian anesthesiology residency programs. After reviewing a list of competencies derived from the Royal College of Physicians and Surgeons of Canada’s National Curriculum, we asked participants to accept, refine, delete, or add competencies. Three rounds were completed between 2022 and 2023. We discarded items with < 50

Abstract BACKGROUND PDLM is a rare and aggressive disease with limited cases reported worldwide and few cases in the pediatric population. Herein we report on clinical, histologic, and molecular/genetic findings of a young child with PDLM and rapid clinical progression. CASE STUDY A 12-year-old right-handed male presented with two months of intermittent fevers, progressive frontal headaches, lethargy, vomiting, and weight loss, and one month of focal seizures with altered awareness, speech arrest, eye deviation, and tonic posturing. Examination revealed bilateral papilledema and signs of increased intracranial pressure. A brain CT demonstrated increased density of the anterosuperior right frontal lobe and punctate focus of increased density along the left frontal lobe suggestive of hemorrhage. MRI revealed diffuse leptomeningeal thickening and enhancement throughout the brain and spinal cord. At biopsy, the frontal lesion was noted to be grossly abnormal and discolored, and on pathology demonstrated a melanocytic neoplasm infiltrating the subarachnoid space and extending into Virchow-Robin spaces. Tumor cells stained strongly for HMB45, vimentin, Melan-A, and PRAME and were BRAFV600E negative. RNA sequencing was negative for structural variants, Whole exome sequencing revealed a Tier I missense variant in NRAS (c.181C>A) among other copy number variations and loss of heterozygosity. Comprehensive ophthalmologic and dermatologic examinations as well as whole body PET/CT did not reveal any other sites of disease. He was due to commence immunotherapy with combination PD-1/CTLA-4 inhibitors but developed status epilepticus and raised intracranial pressure, warranting ventriculoperitoneal shunt insertion. Three days later, he had further deterioration with altered level of consciousness, hypertension, eye deviation, and vomiting. CT brain revealed large bifrontal hematomas with mass effect and care was redirected to palliation. CONCLUSION PDLM can be challenging to diagnose with a rapidly progressive course. Advanced molecular diagnostics may provide new targets for precision therapy, though overall outcomes remain dismal.

OBJECTIVE:The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs). BACKGROUND:Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs. METHODS:A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs. RESULTS:Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds. CONCLUSIONS:We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.

BackgroundWhile virtual care services existed prior to the emergence of COVID-19, the pandemic catalyzed a rapid transition from in-person to virtual care service delivery across the Canadian health care system. Virtual care includes synchronous or asynchronous delivery of health care services through video visits, telephone visits, or secure messaging. Patient advisors are people with patient and caregiving experiences who collaborate within the health care system to share insights and experiences in order to improve health care. ObjectiveThis study aimed to understand patient advisors’ perceptions related to virtual care and potential impacts on health care quality. MethodsWe adopted a phenomenological approach, whereby we interviewed 20 participants who were patient advisors across Canada using a semistructured interview protocol. The protocol was developed by content experts and medical education researchers. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Data collection stopped once thematic saturation was reached. The study was conducted at Queen’s University, Kingston, Ontario. We recruited 20 participants from 5 Canadian provinces (17 female participants and 3 male participants). ResultsSix themes were identified: (1) characteristics of effective health care, (2) experiences with virtual care, (3) modality preferences, (4) involvement of others, (5) risks associated with virtual care encounters, and (6) vulnerable populations. Participants reported that high-quality health care included building relationships and treating patients holistically. In general, participants described positive experiences with virtual care during the pandemic, including greater efficiency, increased accessibility, and that virtual care was less stressful and more patient centered. Participants comparing virtual care with in-person care reported that time, scheduling, and content of interactions were similar across modalities. However, participants also shared the perception that certain modalities were more appropriate for specific clinical encounters (eg, prescription renewals and follow-up appointments). Perspectives related to the involvement of family members and medical trainees were positive. Potential risks included miscommunication, privacy concerns, and inaccurate patient assessments. All participants agreed that stakeholders should be proactive in applying strategies to support vulnerable patients. Participants also recommended education for patients and providers to improve virtual care delivery. ConclusionsParticipant-reported experiences of virtual care encounters were relatively positive. Future work could focus on delivering training and resources for providers and patients. While initial experiences are positive, there is a need for ongoing stakeholder engagement and evaluation to improve patient and caregiver experiences with virtual care.

# 01. Near-peer tutoring: an effective adjunct for virtual anatomy learning {#article-title-2} The start of the COVID-19 pandemic caused a shift in medical education from the classroom to the virtual setting. This abrupt change led to an increase in stress among students. In response, McGill

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# Overcoming barriers to pediatric trauma education in low-and middle-income countries {#article-title-2} Trauma remains a leading cause of child mortality and disability worldwide, taking the lives of 1 million children annually. Of all deaths from pediatric trauma, 95% occur in low- and middle-

OBJECTIVESimulation is increasingly recognized as an important supplement to operative training. The live rat femoral artery model is a well-established model for microsurgical skills simulation. In this study, the authors present an 11-year experience incorporating a comprehensive, longitudinal microsurgical training curriculum into a Canadian neurosurgery program. The first goal was to evaluate training effectiveness, using a well-studied rating scale with strong validity. The second goal was to assess the impact of the curriculum on objective measures of subsequent operating room performance during postgraduate year (PGY)-5 and PGY-6 training.METHODSPGY-2 neurosurgery residents completed a 1-year curriculum spanning 17 training sessions divided into 5 modules of increasing fidelity. Both perfused duck wing and live rat vessel training models were used. Three modules comprised live microvascular anastomosis. Trainee performance was video recorded and blindly graded using the Objective Structured Assessment of Technical Skills Global Rating Scale. Eleven participants who completed the training curriculum and 3 subjects who had not participated had their subsequent operative performances evaluated when they were at the PGY-5 and PGY-6 levels.RESULTSEighteen participants completed 106 microvascular anastomoses during the study. There was significant improvement in 6 measurable skills during the curriculum. The mean overall score was significantly higher on the fifth attempt compared with the first attempt for all 3 live anastomotic modules (p < 0.001). Each module had a different improvement profile across the skills assessed. Those who completed the microvascular skills curriculum demonstrated a greater number of independent evaluations during superficial surgical exposure, deep exposure, and primary maneuvers at the PGY-5 and PGY-6 levels.CONCLUSIONSHigh-fidelity microsurgical simulation training leads to significant improvement in microneurosurgical skills. Transfer of acquired skills to the operative environment and durability for at least 3 to 4 years show encouraging preliminary results and are subject to ongoing investigation.