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Background Postgraduate training is a period in which residents develop both their medical competency and their professional identity in an environment of apprenticeship. As situated learning suggests, a critical dimension of such apprenticeship is the mode through which trainees can legitimately participate in the practice before they become experts, in this case physicians. One source of barriers to participation is cultural difference between learner and the clinical environment. Objective To assess the extent cultural differences create barriers for residents, particularly but not exclusively for international medical graduates (IMGs). Methods In 2014–15 a questionnaire was developed with subscales assessing areas such as sense of hierarchy, individuality versus teamwork, and risk tolerance. We refined the instrument by subjecting it to a review panel of experts in postgraduate education followed by “think aloud” sessions with residents. Results Piloting this instrument yielded a Cronbach’s alpha of 0.675. When administered to a larger group of residents and faculty representing many specialties, the Impact of Cultural Differences on Residency Experiences (ICDRE) questionnaire revealed a few items for which the Canadian Medical Graduates and International Medical Graduates differed in their mean opinion. The groups were not substantially different overall, but we did observe an interesting diversity of cultural beliefs within each group. Conclusions We suggest that the ICDRE may be useful in identifying beliefs which may present challenges to an individual resident or in capturing trends in a resident population so that a specialty program can address the trends proactively. The instrument also provides language with which to anchor preceptors’ evaluations of residents’ professionalism and may serve as an interventional coaching tool.

Background Complex social determinants of health may not be easily recognized by health care providers and pose a unique challenge in the vulnerable pediatric population where patients may not be able to advocate for themselves. The goal of this study was to examine the acceptability and feasibility of health care providers using an integrated brief pediatric screening tool in primary care and hospital settings. Methods The framework of the Child and Adolescent Needs and Strengths (CANS) and Pediatric Intermed tools was used to inform the selection of items for the 9-item Child and Adolescent Needs and Strengths-Pediatric Complexity Indicator (CANS-PCI). The tool consisted of three domains: biological, psychological, and social. Semi-structured interviews were conducted with health care providers in pediatric medical facilities in Ottawa, Canada. A low inference and iterative thematic synthesis approach was used to analyze the qualitative interview data specific to acceptability and feasibility. Results Thirteen health care providers participated in interviews. Six overarching themes were identified: acceptability, logistics, feasibility, pros/cons, risk, and privacy. Overall, participants agreed that a routine, trained provider-led pediatric tool for the screening of social determinants of health is important ( n  = 10, 76.9%), acceptable ( n  = 11; 84.6%), and feasible ( n  = 7, 53.8%). Interpretation Though the importance of social determinants of health are widely recognized, there are limited systematic methods of assessing, describing, and communicating amongst health care providers about the biomedical and psychosocial complexities of pediatric patients. Based on this study’s findings, implementation of a brief provider-led screening tool into pediatric care practices may contribute to this gap.

Background Improving health equity and access to the highest possible standard of health care is a key issue of social accountability. Centretown Community Health Centre in Ottawa, Canada has iteratively developed a program to target and serve marginalized and complex populations since 1999. The program implementation was evaluated using a validated implementation framework. Methods Quantitative and qualitative data were collected through a health records extraction ( n  = 570), a client complexity assessment tool ( n  = 74), semi-structured interviews with clients and key stakeholders ( n  = 41), and a structured client satisfaction survey ( n  = 30). Data were analyzed using descriptive statistics and inductive thematic analysis. Results Five hundred and seventy unique clients were seen between November 1–30, 2021. A third of clients (34%) did not have a provincial health card for access to universal health care services, and most (68%) were homeless or a resident of rooming houses. Most clients who reported their income (92%) were at or below Canada’s official poverty line. The total mean complexity score for clients seen over a one-month period ( n  = 74) was 16.68 (SD 6.75) where a total score of at least 13 of 33 is perceived to be a threshold for client biopsychosocial complexity. Clients gained the majority of their total score from the Social support assessment component of the tool. Clients ( n  = 31) and key informants ( n  = 10) highlighted the importance of building relationships with this population, providing wrap-around care, and providing low-barrier care as major strength to the Urban Health program (UH). Key areas for improvement included the need to: i) increase staff diversity, ii) expand program hours and availability, and iii) improve access to harm reduction services. Clients appeared to be highly satisfied with the program, rating the program an average total score of 18.50 out of 20. Conclusions The program appears to serve marginalized and complex clients and seems well-received by the community. Our findings have relevance for other health care organizations seeking to better serve marginalized and medically and socially complex individuals and families in their communities.

ABOUT US: We are a nonprofit, multi-service Community Health Centre (CCHC) that has played an active role in the down town community  of Ottawa Ontario, Canada since 1969. We offer a full range of community services delivered by a diverse team of professionals. Our team includes doctors, nurse practitioners, nurses, social workers, counsellors, dietitians, community developers, health promoters, and outreach workers. CCHC has been offering teaching placements in Primary Care to medical students and residents, as well as nurse practitioners (NP), since 2002. CCHC Primary Care Team has also hosted learners from a variety of other disciplines including nursing (RN students), social workers and medical receptionists. The teaching began through the initiative of a few committed practitioners, with varying levels of support from the Primary Care Team and CCHC; the teaching continues to be primarily led by the Centre’s preceptors Approach: CCHC conducted a program review of its teaching placements in Primary Care. The scope of this program review includes CCHC’s teaching placements for medical students, NP students, and residents from the University of Ottawa (UOttawa). The focus of this review is on both the process (how the program is working) and the outcomes (what the program is achieving). Data were collected through a combination of focus groups, key informant interviews and surveys. All members of the team were involved in as well as past learners and key stake holders such as the University and other Community Health Centers. The review was done by One World INC, lead by Ken Hoffman and a team from Centertown CHC including 2 family doctors, one Nurse practitioner and a manager. The University of Ottawa offered evaluation and research guidance as well as conduction an extensive literature review of teaching in Community Health Centers. Results: CCHC has benefitted from the teaching, primarily through the ability to recruit physicians and NPs; as staff or locums; CCHC has had no difficulty in recruitment in recent years. oMany learners rate the CCHC placements and preceptors highly. A high percentage said they were able to address their learning goals for the placements; they cited their experiences working with vulnerable populations and in team-based care as important parts of their learning. Many learners who responded to surveys said their experience at CCHC contributed significantly to their consideration of a career in team-based primary care in a community setting. oUOttawa says the preceptors and placements at CCHC are evaluated highly by the learners. oThe other team members, nurses, reception, scheduling coordinator, mangers all identify some extra work and logistical issue with having learners, but on the whole felt that the benefits of the program out weigh the extra work. Implications: If we want our learners to practice in team based models, we need to teach them in such models. Our review showed that the educational program meets that goal. Expanding such teaching and learning and opportunities in our communities will support the growth of team work as we move forward  

Introduction: Collaborative practice competencies are essential for safe, effective practice in today’s health care system. Providing learners with formal teaching and assessment opportunities is a requirement for accreditation in medicine and other health professional programs. However, identifying and assessing a trainee’s ability to competently collaborate in practice across educational contexts remains challenging. Further, without common assessment tools for collaborative practice teaching opportunities, ensuring comparability of collaborative practice learning experiences is difficult. To address these challenges, the College of Family Physicians of Canada tasked an interprofessional group of educators to develop a practical ‘How to Guide’ to support educators and facilitate practice change in how we assess and teach the Collaborator Role competencies.As educators, we are often required to work from a variety of educational frameworks: programmatic evaluation objectives, key and enabling competencies and clinical domains of care as examples. By leveraging specific observable behaviours of collaborative practice, the ‘How to Guide’ links these frameworks and provides practical strategies for teaching and assessing these behaviours across educational contexts.Through these practical tools and strategies for teaching and assessment we expect not only to facilitate these processes but also to encourage consistency of programming and to ensure that health professional learners are supported in the attainment of these collaborator competencies.Purpose: This interactive workshop is designed to support educators in medicine and other health professions with teaching and assessing collaborator competencies. With reference to the CanMEDS 2015, participants will reflect on how they teach and assess the collaborator role within their own contexts; compare these opportunities with collaborator role teaching and assessment strategies implemented in Canada; and consider how the ‘How to Guide’ for the Collaborator Role can support their teaching and assessment of collaborative practice competencies.Learning objectives: By the end of this workshop participants will be able to:1. Identify opportunities to teach and assess the collaborator role in their teaching context.2. Describe common teaching and assessment practices for collaborator role competencies3. Access and apply the How to Guide to support their teaching and assessment of the collaborator role.Targeted Population and Stakeholders: Teachers / preceptors, program directors, health professional educators, medical residents and health professional learners, curriculum developers and assessment leadsTimeline: This work took place from 2013 to 2016 to coincide with the release of the 2015 CanMEDS framework. The How-To-Guide will accompany the roll-out across Canada for the 2017 CanMEDS FM (Family Medicine) competency framework.Sustainability and Transferability: The How-To-Guide is relevant to all health professional educators in their role of preparing future health professionals to be competent to practice in integrated and interprofessional care models. The How-To-Guide was created by an interprofessional group of educators to ensure its relevancy to all health professional training programs. The guide is expected to be available for educators on an ongoing basis for the next decade. Its revision would likely coincide with the 10 year-review of the College of Physicians and Surgeons Canada CanMEDs framework in 2025.This workshop will be facilitated in both English and French.

Atrophy of the medial temporal lobe (MTL) occurs with aging, resulting in impaired episodic memory. Aerobic fitness is positively correlated with total hippocampal volume, a heavily studied memory-critical region within the MTL. However, research on associations between sedentary behavior and MTL subregion integrity is limited. Here we explore associations between thickness of the MTL and its subregions (namely CA1, CA23DG, fusiform gyrus, subiculum, parahippocampal, perirhinal and entorhinal cortex,), physical activity, and sedentary behavior. We assessed 35 non-demented middle-aged and older adults (25 women, 10 men; 45-75 years) using the International Physical Activity Questionnaire for older adults, which quantifies physical activity levels in MET-equivalent units and asks about the average number of hours spent sitting per day. All participants had high resolution MRI scans performed on a Siemens Allegra 3T MRI scanner, which allows for detailed investigation of the MTL. Controlling for age, total MTL thickness correlated inversely with hours of sitting/day (r = -0.37, p = 0.03). In MTL subregion analysis, parahippocampal (r = -0.45, p = 0.007), entorhinal (r = -0.33, p = 0.05) cortical and subiculum (r = -0.36, p = .04) thicknesses correlated inversely with hours of sitting/day. No significant correlations were observed between physical activity levels and MTL thickness. Though preliminary, our results suggest that more sedentary non-demented individuals have less MTL thickness. Future studies should include longitudinal analyses and explore mechanisms, as well as the efficacy of decreasing sedentary behaviors to reverse this association.

A range of studies globally demonstrate that the effectiveness of SARS-CoV-2 vaccines wane over time, but the total effect of anti-S antibody levels on risk of SARS-CoV-2 infection and whether this varies by vaccine type is not well understood. Here we show that anti-S levels peak three to four weeks following the second dose of vaccine and the geometric mean of the samples is nine fold higher for BNT162b2 than ChAdOx1. Increasing anti-S levels are associated with a reduced risk of SARS-CoV-2 infection (Hazard Ratio 0.85; 95%CIs: 0.79-0.92). We do not find evidence that this antibody relationship with risk of infection varies by second dose vaccine type (BNT162b2 vs. ChAdOx1). In keeping with our anti-S antibody data, we find that people vaccinated with ChAdOx1 had 1.64 times the odds (95% confidence interval 1.45-1.85) of a breakthrough infection compared to BNT162b2. We anticipate our findings to be useful in the estimation of the protective effect of anti-S levels on risk of infection due to Delta. Our findings provide evidence about the relationship between antibody levels and protection for different vaccines and will support decisions on optimising the timing of booster vaccinations and identifying individuals who should be prioritised for booster vaccination, including those who are older, clinically extremely vulnerable, or received ChAdOx1 as their primary course. Our finding that risk of infection by anti-S level does not interact with vaccine type, but that individuals vaccinated with ChAdOx1 were at higher risk of infection, provides additional support for the use of using anti-S levels for estimating vaccine efficacy. Here the authors provide data from a sub-cohort of the Virus Watch study (19,556 adults) who completed at-home capillary blood sampling on a monthly basis and describe an association between anti-spike antibody levels and risk of SARS-CoV-2 infection.

Combined genotyping/whole genome sequencing and epidemiological data suggest that in endemic settings only a minority of Clostridium difficile infection, CDI, is acquired from other cases. Asymptomatic patients are a potential source for many unexplained cases. We prospectively screened a cohort of medical inpatients in a UK teaching hospital for asymptomatic C. difficile carriage using stool culture. Electronic and questionnaire data were used to determine risk factors for asymptomatic carriage by logistic regression. Carriage isolates were compared with all hospital/community CDI cases from the same geographic region, from 12 months before the study to 3 months after, using whole genome sequencing and hospital admission data, assessing particularly for evidence of onward transmission from asymptomatic cases. Of 227 participants recruited, 132 provided ≥1 stool samples for testing. 18 participants were culture-positive for C. difficile, 14/132(11%) on their first sample. Independent risk factors for asymptomatic carriage were patient reported loose/frequent stool (but not meeting CDI criteria of ≥3 unformed stools in 24 hours), previous overnight hospital stay within 6 months, and steroid/immunosuppressant medication in the last 6 months (all p≤0.02). Surprisingly antibiotic exposure in the last 6 months was independently associated with decreased risk of carriage (p = 0.005). The same risk factors were identified excluding participants reporting frequent/loose stool. 13/18(72%) asymptomatically colonised patients carried toxigenic strains from common disease-causing lineages found in cases. Several plausible transmission events to asymptomatic carriers were identified, but in this relatively small study no clear evidence of onward transmission from an asymptomatic case was seen. Transmission events from any one asymptomatic carrier are likely to be relatively rare, but as asymptomatic carriage is common, it may still be an important source of CDI, which could be quantified in larger studies. Risk factors established for asymptomatic carriage may help identify patients for inclusion in such studies.

New approaches are urgently required to address increasing rates of gonorrhoea and the emergence and global spread of antibiotic-resistant Neisseria gonorrhoeae. We used whole-genome sequencing to study transmission and track resistance in N gonorrhoeae isolates. We did whole-genome sequencing of isolates obtained from samples collected from patients attending sexual health services in Brighton, UK, between Jan 1, 2011, and March 9, 2015. We also included isolates from other UK locations, historical isolates from Brighton, and previous data from a US study. Samples from symptomatic patients and asymptomatic sexual health screening underwent nucleic acid amplification testing; positive samples and all samples from symptomatic patients were cultured for N gonorrhoeae, and resulting isolates were whole-genome sequenced. Cefixime susceptibility testing was done in selected isolates by agar incorporation, and we used sequence data to determine multi-antigen sequence types and penA genotypes. We derived a transmission nomogram to determine the plausibility of direct or indirect transmission between any two cases depending on the time between samples: estimated mutation rates, plus diversity noted within patients across anatomical sites and probable transmission pairs, were used to fit a coalescent model to determine the number of single nucleotide polymorphisms expected. 1407 (98%) of 1437 Brighton isolates between Jan 1, 2011, and March 9, 2015 were successfully sequenced. We identified 1061 infections from 907 patients. 281 (26%) of these infections were indistinguishable (ie, differed by zero single nucleotide polymorphisms) from one or more previous cases, and 786 (74%) had evidence of a sampled direct or indirect Brighton source. We observed multiple related samples across geographical locations. Of 1273 infections in Brighton (including historical data), 225 (18%) were linked to another case elsewhere in the UK, and 115 (9%) to a case in the USA. Four lineages initially identified in Brighton could be linked to 70 USA sequences, including 61 from a lineage carrying the mosaic penA XXXIV allele, which is associated with reduced cefixime susceptibility. We present a whole-genome-sequencing-based tool for genomic contact tracing of N gonorrhoeae and demonstrate local, national, and international transmission. Whole-genome sequencing can be applied across geographical boundaries to investigate gonorrhoea transmission and to track antimicrobial resistance. Oxford National Institute for Health Research Health Protection Research Unit and Biomedical Research Centre.