Rapid, collaborative generation and review of COVID-19 pandemic-specific competencies for family medicine residency training

Background In March 2020, the COVID-19 pandemic disrupted competency-based medical education in Family Medicine programs across Canada. Faculty and residents identified a need for clear, relevant, and specific competencies to frame teaching, learning, supervision and feedback during the pandemic. Methods A rapid, iterative, educational quality improvement process was launched. Phase 1 involved experienced educators defining gaps in our program’s existing competency-database, reviewing emerging public health and regulatory guidelines, and drafting competencies. Phase 2 involved translation, member-checking, and anonymous feedback and editing of draft competencies by residents and other educational leaders. Phase 3 involved wider dissemination, collaborative editing and feedback from residents and faculty throughout the department. Results A total of 44 physicians including residents and faculty from multiple contexts provided detailed feedback, review, and editing of an ultimate list of 33 competencies organized by CanMEDS-FM roles. Broad agreement was obtained that the competencies form reasonable learning outcomes during the COVID-19 pandemic. Conclusions These competencies represent learning objectives reflecting the initial educational mindsets of a wide range of teachers and learners experiencing a global pandemic. The project illustrates a novel collaboration across educational portfolios as a rapid educational response to a public health crisis.


Introduction
The bilingual University of Ottawa family medicine program trains family medicine specialists who are competent to provide comprehensive, compassionate care in any Canadian community. 1 The exceptional circumstances of the COVID-19 pandemic disrupted health systems internationally and forced sudden changes to many training programs including our own in mid-March 2020. Clinical experiences were cancelled or altered abruptly, virtual visits and supervision replaced inperson contact, and resident physicians were redeployed to novel clinical contexts. For example, residents in our program return for a weekly family medicine 'half day back', regardless of their current clinical rotation, allowing a reconnection with a generalist family medicine mindset and practice, and continuity of care and education. However, in March 2020, anticipated surges in patient volumes and physician illnesses and quarantine, and an attempt to minimize clinicians moving between clinical contexts (reducing potential virus spread) led to several major disruptions. Half-day backs were cancelled, electives, leave and teaching and examinations (including the spring certification examination by College of Family Physicians of Canada) were postponed or cancelled, and some residents were re-deployed to under-resourced settings which had not previously hosted residents. Clinical care in family medicine blocks changed dramatically with physical distancing and personal protective equipment requirements, minimal inperson visits (with reduced physical examination) and patient care delivered mostly virtually (phone or video conference), and physicians working remotely and often indirect supervision. All physicians faced new personal and professional challenges. In response to these changes, we launched an adapted, rapid consensus process to identify and define specific COVID-19 related competencies to guide teaching, learning, and feedback in the new clinical reality simultaneously affecting all Departments of Family Medicine across Canada.

Methods
The uOttawa family medicine program is a bilingual (English, French) two-year residency, with a total of 138 residents (PGY1, PGY2) assigned primarily to one of several dozen of community-based practices across Eastern Ontario, or one of seven teaching units (affiliated with five hospitals in the Ottawa region and surrounding rural areas). Each resident is e52 assigned a faculty preceptor, who are overseen by educational leaders who report on resident progress monthly to a variety of Departmental of Family Medicine committees.
We aimed to engage as many residents, faculty members and leaders in the Department as possible using an adapted approach based on the first three steps of the Kern model 2 : problem identification and general needs assessment (step 1), targeted needs assessment (step 2); writing goals and objectives (step 3) (or more specifically learning 'outcomes' in this case 3 ); CanMEDS is a one of the most widely used educational frameworks for organizing health professions competencies [4][5][6] and was chosen to organize competencies to allow their use in other Canadian family medicine programs, and non-family medicine specialties (Royal College of Physician and Surgeons of Canada). Traditional group consensus methods, such as Delphi and Nominal group methods 7 were considered inadequate to meet our urgent timeline to allow for the broad inclusivity needed to capture the contextual relevance of our diverse family medicine training environments and to allow for the timely application of the educational product. Instead, a process of writing, internal peer review, and revision, based on the first three steps of the Kern approach was utilized. 2 The competencies created are really learning outcomes 5 which are specific, and observable and include cognitive (knowledge), affective (attitudinal), and psychomotor (skill and behaviours) outcomes for residents, patients, the health care system, and society. Table 1 provides a summary of the timeline used for the three-phase process that was conducted over a three week period. Rapid iterations of consultations with multiple forms of feedback allowed input from expanding groups of reviewers (faculty, residents). Anonymous feedback through multiple choice, and open-ended questions was tracked in a six-question survey tool (Google Form), with four questions covering basic respondent demographics (to ensure responses from a range of respondents), and openended questions collecting suggested changes. A priori, we decided we would progress to the next phase if >90% of respondents agreed or strongly agreed with the statement on a 5 point Likert scale (anchors: "strongly agree", "agree", "neutral", "disagree", "strongly disagree"). In the phase 3, 95.7% of respondents "agreed" or "strongly agreed" with the statement "As a whole the competencies form reasonable learning outcomes to guide our teaching, learning and feedback for residents during the COVID-19 pandemic."

Results
The process and results are described in Table 2. A total of 33 COVID-19 pandemic-specific competencies were created by the end of the departmental process (Figure 1; see supplemental data). In phase three, anonymous feedback (n = 24) was provided by residents (n = 11, 45.8%) and faculty (n = 11, 45.8%) with a range of career experience (29.2% <5 years, 16.7% 5-20 years, 41.7% >20 years) in rural and urban teaching sites. In the phase 3, 95.7% of respondents "agreed" or "strongly agreed" with the statement "As a whole the competencies form reasonable learning outcomes to guide our teaching, learning and feedback for residents during the COVID-19 pandemic."

Discussion
During a pandemic, clinical care is paramount, and consistent with principles of competency-based medical education. [8][9][10][11][12] We aimed to analyze and capture the evolving professional, societal, patient and educational needs facing our widely distributed Department. The sweeping reality of the pandemic forced rapid educational change, urgent reflection on professional priorities, roles and identity, and creative adaptation of educational experiences to ensure educational relevance. The current project complements concurrent work by the College of Family Physicians of Canada, guiding virtual e54 supervision of learners. 13 Rather than a 'laundry list' of new educational requirements, the competencies defined here are a resource to use in a wide range of educational contexts to guide teaching, learning and feedback. Although 44 residents and faculty contributed feedback and review of the competencies, the true response rate is undetermined, due to nature of the open invitation to provide input. Another limitation is that these competencies, while vetted by faculty from multiple clinical contexts are largely from a single Canadian university which may limit their immediate applicability in other contexts. The process decision to use existing feedback forms also limits the ease of tracking competency attainment.

Conclusion
Our process aimed to rapidly engage a broad range of stakeholders to provide a focused educational response to a public health and medical education crisis. Next steps include a program evaluation, after the pandemic. A program evaluation approach will define and judge the success, shortcomings of the pandemic-related changes made across our complex program. 14 We will be able to judge the impact (intended and unintended) and merit of this rapid medical education pivot with clear questions (eg "Were the competencies attained?" "Were they adequate?" "Are there unmet faculty and residents needs?") answered through a review of existing data sources (eg formative and summative feedback in field notes and end-of-rotation evaluations), and new data sources (interviews, surveys).
Bringing together a wide range of educational stakeholders (departmental leaders, teachers, residents) from across the continuum of medical education (from undergraduate to postgraduate education and faculty development portfolios) produced an integrated approach to curriculum design, implementation and evaluation. This unprecedented collaboration across portfolios (and universities) was an unexpected outcome of this project, and serves as a model for engagement and cooperation during less turbulent times.
Conflicts of interest: The authors deny any conflicts of interest, or financial or personal relationships that could potentially bias this work.
Funding: This project received no specific funding.