What is the best curriculum design for patient care? Discrete rotations? Longitudinal training?

If you had the choice to customize a training program for yourself – or for your residents – which rotational model would you pick: A longitudinal approach, or a more traditional model, consisting of a number of rotations?

During the International Conference on Residency Education’s special plenary debate mossspadaforaLongitudinal or traditional rotations: Which is better for patient care? on Saturday, October 1 (08:00 – 09:00), Fiona Moss,  Dean of the UK’s Royal Society of Medicine and Salvatore M. Spadafora, Vice Dean of Post MD Education at the University of Toronto will go head to head to debate the pros and cons of a rotational model for residents. The context is a healthcare system-wide push towards quality improvement in medical education and training.

This Q&A is a sneak peek into their much-anticipated debate:

ICRE: Without giving everything away, let’s hear your overarching views: In the context of a health system-wide push towards quality improvement and enhanced patient care, which rotational model is best for the training of residents? Can there be such thing as a one-size-fits-all approach to training models?

Fiona Moss (FM): Residents need to acquire the skills that enable them to both care for individual patients and to “look after the system of care”. These latter skills include team working, leadership, and organizational skills, along with the science crucial for quality improvement science. Acquiring these skills cannot be done quickly – and because they are so important for the care of individuals, I favour a model of training that limits the rotational changes experienced by residents.

Sal Spadafora (SS): In a pro/ con debate I must say that I would suggest that traditional rotations are the best way to cover the often varied breadth of specialty training requirements. Traditional rotations provide us with the opportunity to ensure that our learners are exposed to the multiple contexts of clinical care that provides a comprehensive suite of learning opportunities. The reality however, is that one size likely does not fit all and that most of our future approaches to medical education must include a component of individualized or customized learning plans. 

ICRE: Can you give an example from your own professional life that might help explain why it is that you view the particular model above as being the best approach to take in terms of planning resident rotations?

FM: As a senior resident (registrar) in the UK, my program had me essentially spend two years in each of two places. I learned an enormous amount about the ins and outs of working in a single organization, and it was not possible to “rotate” away from difficult situations.  I was able to see the long term impact of quality improvement; develop long term working relationships with a whole range of staff and patients; and to get to know the local primary care practitioners as well as the local population. Because I became part of each institution for a long time, I was given organizational responsibilities, which allowed me to develop organizational skills in a way that would not have been possible in shorter rotations.  In addition, my trainers were able to supervise and appraise my development much more in-depth.

SS: Ironically, my training for my specialty was not that of what we would describe as traditional rotation.  It was site-based longitudinal, and you moved every four to 12 months.  It was felt that if we stayed at a site for long enough, we would “see it all”. We went to a site daily “tarred”; the teachers threw enough “feathers” at us, and hoped that some of them stuck. Not all of us ended up looking like birds. They called them rotations, but there was no structure to them other than showing up at a site for what felt like a very long time, and being assigned to an operating room. I was pretty diligent and assertive, but felt that I really had to advocate and be quite loud to get what I was missing. 

Learning is a partnership, and as much as I want learners to be active, assertive and speak up (and they do), I believe it is our collective obligation to provide some structure and partner with the learners to provide the rotations that are carefully planned, exquisitely supervised, and take into account the integration of patient care/ service and trainee learning. This is what I spent the first portion of my career doing, as a teacher, and then as a Program Director; transforming a longitudinal, site-based approach to true rotations.   

ICRE: Why do you think an analysis/evaluation of training models is important now, in the context of 21st century medical education and the quality improvement movement?

FM: Medical technology and the delivery of patient care have changed hugely over the past 20 years.  To quote a Sir Cyril Chantler writing from the ‘Lancet’ (UK medical journal) in the 1990s, “medicine used to be simple, ineffective, and relatively safe; it is now complex, effective and potentially dangerous”.  This has many implications for training. For example, supervision is now much more crucial, and as new modalities of treatment alter the delivery of care, there are consequential implications for the delivery of resident training.  In addition, we now know so much more about quality and safety improvement; so if training does not include a significant focus on the science,  skills and behaviours necessary for quality improvement,  it  should be considered  incomplete. The need to deliver training in QI should drive links between organizations that train, their training programs and their residents.  Finally, hospitals that deliver good quality care are likely to be “learning organizations”; and these should be the best places for residents training. 

SS: As I said earlier – one size will not likely fit all the learners all the time.  We need to focus less on the label for the model of training.  We should place our focus, instead, on those we train and the patients we care for, as well as the specific key elements of the learning experience.  Current and future program evaluation should focus on the outcomes of learning (which theoretically should lead to better patient outcomes), and components of the learning activities that are essential to the training of a competent physician.  You can likely have the best of both paradigms and the worst of each as well.  It’s not what you do – it’s the way that you do it!  Partnering with learners, exquisite supervision, and a focus on integration of superb patient care and patient safety with individualized learning are the key components of both modern longitudinal and rotation based learning.

ICRE: What can ICRE attendees expect from this debate? How might it be of value to participants who may not directly be involved in the planning of, or participation in, rotational training models?

FM: I hope that those in the audience will see that there perhaps needs to be a greater alignment between residents, their training programs, and the organizations in which they work and train.  Residents are among the most able, ambitious and energetic of our health care professionals, and if they were a greater part of – and more “aligned with” – their educational organizations, this could benefit the clinics/hospitals and their patients, as well as the residents themselves. In addition, this would perhaps drive more hospitals to aim to truly be “learning organizations”.

SS: Well for starters I like a good debate (as my family would say – “he likes to argue and he always thinks he is right!”).  So attendees can expect me to be less “on the fence”, and be a bit more dogmatic about the traditional model of rotational learning as the quintessential way to produce the model physician for the 21st century. 

I think the session will be valuable to the reflective educator who can expect to find the good, the bad and the ugly of each model exposed for what it is, and decide for themselves if they want a polarized, off the rack item to fit onto each learner and each learning environment.  I suspect participants will take in the good of each model, avoid the bad of each model and shun the ugly of each model.  The result may be a future that is awash with thoughtful, customized, individualized, “bespoke” rotations that focus on the learner and the patients!   

Fiona Moss is a most capable opponent to debate – expect sparks to fly!  

If you can’t join us live for the debate, check back here the week of September 25th, for details on how to stream the debate live.

To view the full lineup of plenaries, workshops and sessions taking place during ICRE 2016, click here.

#KeyLIMEPodcast 115: Wasting time? And Resident Duty Hours.

Hey?  What are you doing right now?  Ok now?  How about now?  Sure… but right now… what are you doing?

I don’t think this is how time-motion studies work… would it not be off-putting if someone with a clipboard and a white coat followed you around all day?  The Key Literature in Medical Education podcast jumps into the world of time-motion studies this week.  The context for the research is the impact of the ACGME resident duty hour restrictions on day-to-day clinical work.

In episode 113 we talked about the influence of these administrative changes on patient outcomes. Now we can dig a bit deeper and figure out what happens minute to minute in the life of a resident.

On to the show! (i.e. the podcast is here.).  Or if you want to wade (not jump) in, check out the abstract below.

– Jonathan


KeyLIME Session 115 – Article under review:

New KeyLIME Podcast Episode Image

Leafloor CW, Lochnan HA, Code C, Keely EJ, Rothwell DM, Forster AJ, Huang AR Time-motion studies of internal medicine residents’ duty hours: a systematic review and meta-analysis. Adv Med Educ Pract. 2015. 17(6):621-9

Reviewer: Jason Frank (@drjfrank)


Resident duty hours (RDH) is a frequent topic in the KeyLIME podcast. Loyal listeners will recognize the decades-long debates, the hardened positions of various advocates, and more recently, the emergence of evidence to finally guide policy and educational decision-making. (You can find some previous episodes of KeyLIME on RDH here: #62 and #76) See the Canadian task force review of the recent lit at www.residentdutyhours.ca). Previous reviews have covered the impact of changes to RDH (especially in the US), the rationale for changes, how loathed many changes are, and what impact they have had. Hint: it’s not patient safety. More recently, a national RCT of RDH changes was published in the NEJM to great fanfare (see KeyLIME episode #113, where we were disappointed in the study).

Linda found today’s paper in a journal that I had not previously heard of, and it addresses an important aspect of the RDH discourse: “what exactly do residents spend their precious time on?” Linda knows I have an interest in the obscure sub-genre of observational research called “time and motion studies”, which basically record what a population does in a given time period.


Leafloor et al, from the Ottawa Hospital [disclosure: I work at the Ottawa Hospital, but it is a big institution and did not know anything about this paper before reading it]. The authors set out to do an overview of time and motion studies of residents in Internal Medicine. They paid particular attention to changes related to US (ACGME) RDH policies.

Type of Paper

Systematic review

Key Points on Methods

The authors searched 4 English databases from 1941 to 2013, looking for time and motion studies, internal medicine related disciplines, and duty hour related terms. They included only those that involved only direct observations. All other methods were excluded (they even tried out one published method, found it unreliable, so excluded it). They developed a taxonomy of 9 daily activities using a “modified Delphi method”, then didn’t use it to classify the data from papers. They used 5 categories instead: patient care, communication, transit, education, & personal/other. They pooled the data and performed descriptive stats.

Key Outcomes

The search found 468 records from the search that yielded 8 includes. Residents per study ranged from 2-35, total observation time was a mean of 388 hours. The overall results were that a typical on-call shift involved 41.8% of time spent in patient care, 19.7% personal/other, 18.1% communication, 13.8% education, and 6.6% transit. Post ACGME policy changes, the % were not statistically significant. Notably, education time decreased by ~6% and communication time increased by about the same.

Key Conclusions

 The authors conclude…

The authors conclude that time and motion studies provide useful insights into Internal Medicine resident activities. They also found a lack of standardization of terms, taxonomies, or methodologies in meded studies.

Spare Keys – other take home points for clinician educators

  1. Time and motion studies are a powerful sub-genre of observational research to apply to medical education problems.
  2. Reviews of a diverse group of studies can be very influential–but authors really need to pay attention to their methods to make the work defensible and comprehensive.
  3. Systematic reviews can be great resident research projects, and highly publishable.

Shout out

My colleague at the Royal College, Tanya Horsley, is a world-renowned systematic review methodologist. Look up her name when you are embarking on one of these reviews and you will find some great methods papers to model your approach on.

Listen to the podcast here

A Conversation on Competency-based #Meded with the ICE Editorial Board

The ICE blog is trying a low stakes experiment today.  We’ve added audiovisual.  Apparently the “YouTube” is all the rage with kids these days… who knew??

The conversation is between three members of the ICE editorial board (Rob Cooney, Teresa Chan and me.)  This video was recorded as part of a virtual faculty development program for early career Clinician Educators.  (As a side note, this virtual course is one of the most interesting projects I’ve contributed to in the past few years.  Details here.)

In this episode we discuss:

  1. What are the essential elements that define a CBME curriculum?
  2. Why make the change to CBME … wasn’t (P)GME OK for the last 5 decades?
  3. What is programmatic assessment?
  4. Is ‘time’ really gone?
  5. What can I do this year to align my program to a CBME model?

So… on with the show.

PS: We’re interested to hear your thoughts on this experiment.  Leave a comment below or cast your vote in our Twitter poll.

Blogging about Blogs: Don’t Forget the Bubbles

(This is the final part of the ICE Blog’s “Blogging about blogs” series, edited by Anthony Llewellyn and Teresa Chan. Click on the following links to see previous posts: #1#2 #3 #4 and #5 )


This post is an interview by Anthony Llewellyn with Andy Tagg of Don’t Forget the Bubbles (DFTB).  The aim of this blog is to create a practical, high-quality paediatric education resource for health professionals.  DFTB does this through collaboration – getting more people involved in creating online content (Free Open Access Medical Education).  The site is primarily run by four authors who are all paediatricians Tessa Davis, Henry Goldstein, Ben Lawton and Andy Tagg.

Their most popular post to date has had about 22,000 page views and they have regular site traffic of around 750 views per day.  While the latest posts are often the main draw to the site, the blog also serves as a repository for core information specific to paediatric medicine that they may not find on other websites.

One interesting fact about the DFTB crew is that even though they have been going since 2013 they have yet to meet in person.  DFTB is a true international virtual collaboration.

Q: When did you start your blog?

A: We started around July 2013.

Q: How many people are involved?

A: The four of us regularly contribute and act as editors but we use a collaborative model with many individuals contributing single or multiple posts.

Q: How would you describe your audience?

A: A mixture of specialities read the blog – paediatrics, emergency medicine and primary care as well as nurses and allied health professionals.  Although it was initially aimed at trainees in paediatrics, it has grown.

Q:  Can you describe your process for generating content?

A: Each of the four of us contribute articles based on our areas of special interest.  We don’t set a specific agenda. We may post on recent public health policies as related to paediatrics (immigration health, vaccination) or recent journal articles (updated ILCOR neonatal or paediatric guidelines). We might post talks we have done to trainees to make them available to a wider audience. But more often than not, we post an answer to a specific question that we can’t find anywhere else.

Q: What’s your technology stack (i.e. how do you host your site, how do you code it, do you have a CMS, do you use any integrations e.g. Facebook, Twitter, Google etc…?)

A:  It is a WordPress-based blog. We cross post to Facebook as well as promoting the posts by Twitter and Google +, as  well as LinkedIn. We self host the site.

Q:  What’s one interesting thing you have learned through the process of developing a MedEd blog / website?

A: I might give a talk to our registrars that 15-30 people attend.  I will have put in a lot of effort to write, rehearse and give the talk, but the impact is small.  I can put the same amount of effort into recording the same post and putting it online and reach many more people. That is extremely satisfying.

Q: DFTB is a site that focuses on learning through incorporating assessments.  How do you create goals and objectives for your learners / audience?
(Especially since you don’t REALLY know who’s reading OR do you?)

A: We don’t really know who is reading.  We write for ourselves and each other using Basecamp to collaborate. We cross edit the posts. When I write a post I think of a topic that I want to know more about.  I then write the questions I want answered before I research the topic.  We try and take a practical approach to answering day-to-day problems.

#KeyLIMEPodcast 114: What does it mean to be ‘competent’ as a program director

The Key Literature in Medical Education podcast reviews a competency framework for program directors (i.e. the senior education administrator responsible for a specialty training program for physicians).  Many clinicians and educators suggest that the program director position is the most influential/important role in the medical education spectrum.  A program director oversees the training of a physician to enter unsupervised practice.  And the influence of this period of training will be preserved for decades.  (See Episode 80)

If you’re wondering what are the competencies necessary for this position, this paper tackles it.  (TEASER ALERT)  However, Jason suggests that there is an important component missing.  Check out the podcast here. for more details.

– Jonathan

Continue reading “#KeyLIMEPodcast 114: What does it mean to be ‘competent’ as a program director”

A Day in the Life of A CE: Jonathan Sherbino 

By: Jamiu Busari 

Jonathan Sherbino, MD, MEd, FRCPC, FAcadMEd


Editor-in-Chief, ICE blog

Co-Host, KeyLIME Podcast

Chair, Emergency Medicine Specialty Committee, Royal College of Physicians & Surgeons

Co-chair, Clinician Educator Area of Focused Competence (Diploma), Royal College of Physicians & Surgeons

Co-chair, International Conference on Residency Education.

Associate Professor, McMaster University


1. What is your clinical/educational background? Continue reading “A Day in the Life of A CE: Jonathan Sherbino “