In 2017, the General Surgery program began implementing the Competence by Design model as outlined by the RCPSC. As this program was an early adopter of CBME, we identified an opportunity to learn from this experience by examining the experiences of this change process. We explored the experiences of program leaders, faculty and residents in the implementation of Competency-Based Medical Education (CBME), compare planned versus enacted CBME implementation, and identify adaptations for effective CBME implementation. Rapid Evaluation methodology and the Core Components Framework were employed to evaluate CBME implementation. Interviews and focus groups were conducted with program leaders, faculty, and residents. They were transcribed and analyzed abductively. We met with program leaders to review themes and discuss current and future adaptations. The study was conducted at a tertiary care centre in Southeastern Ontario, Canada. We sent email invitations to participate all program leaders/staff, faculty, and residents of the General Surgery program. Nineteen program members (program leaders/staff and faculty n = 9; residents n = 10) participated in the study. Participants highlighted challenges enacting the planned implementation of CBME. Three themes represented participants’ perceptions and experiences of CBME implementation: (a) complex systems change, (b) opportunities for growth, and (c) paving the way forward. Themes were subsequently mapped to adaptations identified by the program. This study provides insight into how CBME was enacted within a Canadian General Surgery training program. We identified adaptations that can be used to address challenges and enhance the quality of CBME implementation.

IntroductionHIV pre-exposure prophylaxis (PrEP) utilization in Ontario is concentrated in two large urban centers, resulting in geographic and structural inequities in access. Little is known about adoption in Public Health Sexual Health Clinics (PHSHCs) or the implementation factors influencing uneven uptake. This study aimed to: (1) assess the extent of PrEP adoption in PHSHCs; (2) identify barriers and facilitators affecting implementation; and (3) explore factors supporting successful and equitable PrEP implementation.MethodsSemi-structured interviews were conducted with 18 staff and managers across 12 PHSHCs. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis, while the Health Equity Implementation Framework (HEIF) was applied to examine structural, organizational, and socio-cultural influences on PrEP access. Clinics were categorized into five adoption categories using the diffusion of innovations model. A content analysis was done to identify common facilitators, barriers, and equity-relevant factors distinguishing clinics at different adoption categories.ResultsPrEP adoption varied widely across clinics. Two were innovators, providing on-site PrEP; three were early adopters with formal referral pathways; four were early majority, relying on informal referrals; and five lacked established services. Facilitators included strong PrEP knowledge and beliefs, inter-organizational partnerships, and supportive organizational cultures. Key barriers were post-COVID-19 service recovery constraints, limited external prescribers, insufficient medication funding, constrained internal capacity, and social individual-level barriers. Differences between advanced and less advanced adopters reflected perceived relative advantage of PrEP within PHSHC mandates, workflow integration complexity, and the presence of a supportive learning climate. Equity-focused analysis highlighted obstacles affecting clients experiencing socioeconomic disadvantage, rurality, stigma, and limited healthcare navigation capacity.ConclusionThis study highlights that inequities in PrEP access across Ontario PHSHCs are shaped not only by clinic readiness but also by broader structural and organizational conditions. These findings advance understanding of PrEP adoption outside large urban centers, identifying barriers and strategies to expand services and enhance implementation readiness. Using the CFIR and HEIF, we delineated factors to support adoption in early-stage PHSHCs while learning from those with successful integration. Addressing these factors will be critical to expanding equitable access to PrEP and advancing HIV prevention goals.

Background: Lifestyle Medicine (LM) education offers potential benefits for medical students for improving medical students’ health and clinical knowledge/skills. However, since LM education has not been consistently integrated into undergraduate medical education, there is a need to better understand the current literature about LM programs, including their characteristics, reporting, and application. Methods: A search of multiple databases yielded 7674 articles from 2012 to 2024. Handsearching of reference lists and extraction from review articles yielded 82 additional articles. Two hundred and five articles met the inclusion criteria. LM programs were assessed in relation to their context, dose and intensity, delivery, and outcomes. Results: The characteristics of LM programs varied considerably. LM programs generally focused on one pillar, specifically nutrition and substance use, and were often taught by interprofessional teams using multiple pedagogical strategies. Studies typically assessed outcomes at Levels 1 and 2 of the Kirkpatrick models of evaluation. Important limitations were identified in both the reporting quality, particularly the lack of demographic and costs, as well as the strength of study designs, like focus on short-term outcomes. Conclusions: To enhance the quality of LM programs, future work can adopt holistic approaches to LM and examine sustainability of LM programs in diverse contexts.

Canadian healthcare, particularly family medicine, is experiencing a capacity crisis. To address this challenge, systems-level reform is required. Specific to medical education, there is an urgency for educational institutions to prepare the next generation of physicians to meet Canadians’ healthcare needs. This will require not only the expansion of the number of physicians trained, but consideration of the specialty mix and types of practice those physicians are prepared to undertake. Building on an existing collaborative partnership, the Queen’s-Lakeridge Health Doctor of Medicine - Family Medicine Program (QLH MD FM) launched in 2023. This initiative is designed to address the needs of Canadians through purposeful recruitment and the development of learners interested in, and committed to, careers in family medicine. This paper shares the experiences of the QLH MD FM team, and the steps taken in conceptualizing and implementing this educational initiative. A program description is provided, focusing on the six program pillars: (a) admissions, (b) curriculum, (c) faculty and staff engagement, (d) community engagement, (e) infrastructure and supports, and (f) learner experience. The QLH MD FM Program is an innovative approach to medical education that emphasizes an authentic focus on addressing the complex healthcare needs of individuals and their communities.

Introduction: In competency-based medical education (CBME), specifically entrustable professional activities (EPAs), timely feedback is essential because delays can distort assessor recall and performance documentation. Prior work links longer timelag to reduced feedback quality, but its effects across thresholds and outcomes remain unclear. This study examines these relationships using statistical analyses, incorporating artificial intelligence (AI) tools to standardize extraction of narrative feedback metrics. Methods: We performed a retrospective cross-sectional study of internal medicine resident EPA assessments, each including two narrative sections (‘General Feedback,’ ‘Next Steps’), entrustment scores (0-4), and completion dates. Pretrained transformer-based models estimated sentiment positivity (0-1) and Quality of Assessment for Learning (QuAL) scores (0-5). We manually refined outputs, subsequently fitting datapoints for ordinal logistic, binary logistic, and linear regression. Exploratory analyses identified timelag thresholds linked to changes in feedback metrics. Results: 301 assessors evaluated 1,147 EPAs for 111 residents, with a 7-day median timelag (IQR: 21). Longer timelag was associated with lower QuAL (OR=0.997/day; p < 0.05), fewer words (-0.07words/day; p<0.05), and higher odds of empty comments (OR=1.003/day; p < 0.01). Effects emerged sequentially: transient increases in entrustment around seven days, followed by dose-dependent declines in quality from 14 days and reductions in feedback length thereafter. Beyond 100 days, comments became uniformly brief with higher positivity and entrustment, suggesting reduced specificity and recall. Conclusion: Delayed completion meaningfully affects feedback quality, completeness, and tone. Findings support 7-14 day completion targets and flagging EPA assessments beyond 100 days as unreliable. AI-assisted extraction of narrative metrics may support standardized, scalable EPA assessment analysis in CBME.

Pre-exposure prophylaxis (PrEP) in Ontario remains concentrated in large cities, leaving smaller urban and rural communities underserved. To inform targeted expansion, we interviewed 28 primary care providers (family physicians, trainees, public health nurses, clinic managers, and practice leads) working outside major metropolitan areas. Recruitment used multiple outreach methods, and interviews were transcribed and thematically analyzed. Half of participants had direct PrEP experience. Providers cited limited training, knowledge gaps, few continuing-education opportunities, staffing shortages, and lack of administrative support as barriers. Structural forces, stigma, high costs, transportation barriers, further limited access, intersecting with poverty, racism, and substance use, and affecting equity-deserving groups beyond gay and bisexual men. Participants recommended province-wide competency-based training, task-sharing through medical directives, normalization of PrEP in clinical discussions, broader awareness campaigns, and nurse-led models. Findings highlight the need to strengthen provider capacity while addressing social determinants to achieve equitable PrEP uptake outside Ontario's major cities.

PURPOSE:This study explores the partnership experiences of patient and health care professional (HCP) subject matter experts (SMEs) in cocreating educational content and examines their reflections on how to better support educational partnerships in future initiatives. METHOD:In this qualitative, exploratory study, semistructured interviews of patient and HCP SMEs were conducted between February and August 2022. Interviews were conducted with videoconferencing software, audio recorded, and transcribed verbatim. Interviews were analyzed using an iterative, inductive approach informed by reflexive thematic analysis. RESULTS:Eight patient SMEs and 6 HCP SMEs were interviewed. Three themes and 8 subthemes were developed to represent SMEs' experiences. The overarching themes included (1) building authentic partnerships, (2) developing equitable partnership processes, and (3) setting the stage for successful cocreation. Authentic partnerships were conceptualized as relationships that foster meaningful engagement, provide opportunities for learning and growing together, and require navigation of tensions and constraints. Equitable partnership processes included creating shared expectations and facilitating open and clear communication among partners. Participants discussed how future partnerships can benefit by embracing diversity and innovation, encouraging sustained engagement, and facilitating high-quality processes and products. CONCLUSIONS:The findings of this study highlight that positive cocreation experiences are characterized by building authentic partnerships, developing equitable partnership processes, and setting the stage for successful cocreation. Future work can build on these findings to further explore how to best foster cocreation within educational partnerships.

Primary care providers (PCPs) in Canada frequently report limited knowledge and confidence in prescribing HIV pre-exposure prophylaxis (PrEP). To address this gap, we developed and evaluated an online educational module designed to enhance PCPs' knowledge and PrEP-related clinical skills. Pre- and post-training surveys (n = 38 and n = 20, respectively) showed substantial improvements: understanding of PrEP eligibility increased by 46%; knowledge of medications and monitoring by 55-180%; skills in medication management by 57-68%; skills in client monitoring by 47-84%; and knowledge regarding PrEP discontinuation by 84%. All participants (100%) agreed that the module met their expectations and was highly valuable, applicable, and useful to their clinical practice. Qualitative feedback highlighted the need for audio narration, more downloadable materials, and more inclusive, patient-centered content. Overall, these findings indicate that the online module effectively enhances PCPs' readiness to prescribe oral PrEP and addresses key gaps in HIV prevention training.

9025 Background: MO training programs across Canada implemented CBME in 2018. Early implementation focused primarily on immediate “structural” changes, and included the adoption of new stages of training, new assessment practices and the creation of Competence Committees. To explore elements that would reflect broader and transformational change related to a true shift to an individualized and competency-based approach to education, program leaders sought to identify, develop, and pilot indicators that could be used by programs to evaluate their implementation of the Competence by Design (CBD) model. It was anticipated that implementation and evaluation of these indicators would be challenging. Methods: In phases one and two of the study, program leaders established a consensus regarding qualities they considered to transformative, and qualitative information regarding how these qualities are reflected in programs was obtained. In phase three, electronic resident portfolios at 2 sample sites were investigated for data regarding specific indicators to determine the feasibility of use by program directors to track implementation progress and aid in program review. Opinions of program leaders in all 14 Canadian programs were obtained through a consensus process. Educators from all sites were invited to participate in semi-structured interviews and a 100% response rate obtained. Data from the 2 sample sites was collected from portfolios, de-identified and reported in aggregate to help maintain confidentiality. Results: 7 key priority indicators were identified. These centered around 6 themes: direct observation, personal learning plans, curricular change, coaching, data sources used by Competency Committees and general concerns about CBD. Variability was found in the extent of implementation of these across programs and in adaptations made locally. At the 2 sample sites, extraction of key metrical indicators from resident portfolios had to be completed manually and was challenging as electronic databases had not been designed to allow easy review and analysis of these specific indicators. Conclusions: Program leaders of Canadian MO training programs were able to reach consensus regarding key data indicators they believe to be transformative and reflective of core CBD principles. Despite this consensus, variability was found in the implementation of these across programs and practical challenges encountered in extracting data related to key indicators from resident portfolios at 2 sample sites. To provide program leaders with data they feel is important for optimal CBD implementation, electronic databases will need ongoing attention and adaptation to facilitate access to key indicators considered important for program review and evaluation.

BACKGROUND:The rapid evolution of genetic testing and availability of information has necessitated increased surgeon participation in genetics-related tasks. We sought to characterize knowledge, perceptions, attitudes, and barriers pertaining to genetic literacy among Canadian surgeons who manage patients with a hereditary predisposition to or confirmed cancer. METHODS:We distributed a Web-based survey to surgeons across Canada from June to December 2023 through relevant surgical societies. We analyzed quantitative and narrative data from the survey descriptively and thematically. RESULTS:We included 57 participants from 8 provinces (response rate 10%). Many surgeons (28/45, 62%) reported performing risk assessment, but 16% (7/45) reported counselling and 29% (13/45) reported ordering genetic testing. Surgeons reported low confidence in ordering testing and in interpreting and discussing implications of testing results. Most surgeons (35/39, 90%) expressed a desire for improvement in their knowledge and in their confidence in hereditary cancer genetics. Approval and funding for testing, referral to a genetic counsellor or medical geneticist, and availability of genetics clinics were reported as extreme barriers to providing care. CONCLUSION:Practising surgeons in Canada participate in many genetics-related tasks, but they report low confidence and face barriers to genetic literacy. There is a need and desire for interventions targeting genetic literacy among surgeons in Canada.

Canada has been experiencing an opioid use crisis, and urgent efforts are being made to stem the tide. With funding support from Health Canada, the Association of Faculties of Medicine of Canada (AFMC) recently developed a series of asynchronous online bilingual modules to educate key players across the medical education spectrum on chronic pain and opioid use. The curriculum for the modules which informed the development of the Patient-Physician Partnership Toolkit was co-created through an authentic collaboration between healthcare professionals (HCPs), and patient subject matter experts who were patients with lived experience. This discussion paper presents the methods and procedures employed in co-creating the patient toolkit with patient SMEs and presents the lessons learned for improving future partnerships.

Background: Despite increased access to HIV pre-exposure prophylaxis (PrEP) in Canada, familiarity and experience among primary care providers (PCPs)—including family doctors and those working with key populations—remains limited. To understand the barriers and facilitators of PrEP familiarity and experience, we conducted a situational analysis in PCPs in sub-urban and rural Ontario. Methods: We surveyed a non-probabilistic sample of PCPs using an online questionnaire, designed with the Consolidated Framework for Implementation Research (CFIR). Poisson regressions with robust variance were used to assess the relationship between CFIR domains, sociodemographic, and practice characteristics on both PrEP familiarity and experience. Results: A total of 54 PCPs participated (6% response rate), comprising 80% physicians and 20% nurses. Nearly 30% of the sample worked with key populations, including sexual health clinics and community care centers, 18% of respondents reported high familiarity with PrEP, and 44% reported PrEP experience (referred, started a conversation, or prescribed). PrEP familiarity and experience were associated with working in an organization serving key populations, working with gender minorities, and having colleagues providing PrEP. Providers with a positive perception of PrEP and its necessity for populations at risk were more likely to have PrEP-related experience. Higher familiarity and experience were reported by PCPs with specific clinical skills related to PrEP, and with the perception that PrEP was compatible with their practice as primary provider. Conclusions: Our findings suggest that organizational support, and additional training and education would facilitate PrEP provision by PCPs in suburban/rural Ontario.

Africa is currently facing unprecedented growth in its cancer burden. Training an adequate number of skilled physicians is critical to addressing this challenge. We examine African oncology faculty’s professional development (PD) activities, associated barriers, enablers, satisfaction levels, and highlight the implications for improving the quality of the oncology faculty workforce in SSA. We surveyed oncology faculty (n = 69) through the African Organization for Research and Training in Cancer listserv and conducted semi-structured interviews with nine (n = 9) faculty involved in African oncology training programs to ascertain their views on PD activities including, method of delivery, curriculum development, teaching, learning, and mentorship. Descriptive, inferential, and thematic analytical techniques were used to analyze the data. Ninety-two percent of African oncology faculty have participated in a PD activity and about 34

Objective: As competency-based medical education is being implemented across Canada, there is an increasing need to evaluate the progress to date, including identification of strengths and weaknesses, to inform program development. Ophthalmology is preparing for a national launch in coming years. The purpose of this study was to describe key stakeholders' lived experiences in the competency-based medical education foundation-of-discipline stage in one ophthalmology department. Design: Using a case-study approach, a qualitative rapid-cycle evaluation was conducted during the 2018-2019 academic year. Participants: Residents, faculty, academic advisors, competence committee members, the program director, the program administrator, and the educational consultant were invited to participate in the program evaluation. Methods: The rapid-cycle evaluation consisted of 2 evaluation cycles, with the first round of interviews and focus groups occurring in October 2018 and the second round in March 2019. Recommendations were implemented in November 2019 and June 2019. All data were analyzed thematically using NVivo. Results: Three main themes emerged across all data sets: developing a shared understanding (e.g., role expectations and changes to assessment), refining assessment processes and tools (e.g., the need for streamlining and clarification), and feedback (e.g., perceived benefits and value of narrative comments). Conclusions: Exploring lived experiences in this study resulted in positive and immediate improvements to the residency program. The recommendations and approach will be useful to other Canadian departments and institutions as they prepare for Competence by Design.

Phenomenon: Competency-based medical education (CBME) relies on workplace-based assessment (WBA) to generate formative feedback (assessment for learning-AfL) and make inferences about competence (assessment of learning-AoL). When approaches to CBME rely on residents to initiate WBA, learners experience tension between seeking WBA for learning and for establishing competence. How learners resolve this tension may lead to unintended consequences for both AfL and AoL. We sought to explore the factors that impact both decisions to seek and not to seek WBA and use the findings to build a model of assessment-seeking strategy used by residents. In building this model we consider how the link between WBA and promotion or progression within a program impacts an individual's assessment-seeking strategy. Approach: We conducted 20 semi-structured interviews with internal medicine residents at Queen's University about the factors that influence their decision to seek or avoid WBA. Using grounded theory methodology, we applied a constant comparative analysis to collect data iteratively and identify themes. A conceptual model was developed to describe the interaction of factors impacting the decision to seek and initiate WBA. Findings: Participants identified two main motivations when deciding to seek assessments: the need to fulfill program requirements and the desire to receive feedback for learning. Analysis suggested that these motivations are often at odds with each other. Participants also described several moderating factors that impact the decision to initiate assessments, irrespective of the primary underlying motivation. These included resident performance, assessor factors, training program expectations, and clinical context. A conceptual framework was developed to describe the factors that lead to strategic assessment-seeking behaviors. Insights: Faced with the dual purpose of WBA in CBME, resident behavior in initiating assessment is guided by specific assessment-seeking strategies. Strategies reflect individual underlying motivations, influenced by four moderating factors. These findings have broad implications for programmatic assessment in a CBME context including validity considerations for assessment data used in summative decision-making including readiness for unsupervised practice.

Objectives Medical Assistance in Dying (MAiD) was legalized in Canada in 2016, necessitating greater education and training in MAiD for physicians and nurse practitioners. To meet this need, the Canadian MAiD Curriculum (CMC) was developed to offer a nationally accredited, comprehensive, bilingual, hybrid (synchronous and asynchronous) educational program to support and enhance the practice of MAiD in Canada. Methods This work describes the process of developing the CMC, including its guiding principles and framework. The CMC was guided by constructivism and adult learning theory, preliminary literature review, 5 key principles based on a needs assessment survey, as well as consultation with diverse partners. Results Seven modules were developed: (1) foundations of MAiD in Canada, (2) clinical conversations that includes MAiD, (3) how to do an MAiD assessment, (4) capacity and vulnerability, (5) providing MAiD, (6) navigating complex cases with confidence, and (7) MAiD and mental disorders. An eighth topic on clinician resilience and reflection was woven into each of the 7 modules. Conclusion This curriculum ensures that consistent information is available to healthcare providers concerning the practice of MAiD in Canada. To ensure sustainability, the CMC will continue to be updated alongside the evolution of MAiD policy and services in Canada.