Background: Residency training programs in Canada are undergoing a mandated transition to competency-based medical education (CBME). There is limited literature regarding resident perspectives on CBME. As upper year residents act as mentors and assessors for incoming cohorts, and are themselves key stakeholders in this educational transition, it is important to understand how they view CBME. We examined how residents who are not currently enrolled in a competency-based program view that method of training, and what they perceive as potential advantages, disadvantages, and considerations regarding its implementation. Methods: Sixteen residents volunteered to participate in individual semi-structured interviews, with questions focussing on participants’ knowledge of CBME and its implementation. We used a grounded theory approach to develop explanations of how residents perceive CBME. Results: Residents anticipated improved assessment and feedback, earlier identification of residents experiencing difficulties in training, and greater flexibility to pursue self-identified educational needs. Disadvantages included logistical issues surrounding CBME implementation, ability of attending physicians to deliver CBME-appropriate feedback, and the possibility of assessment fatigue. Clear, detailed communication and channels for resident feedback were key considerations regarding implementation. Conclusions: Resident views align with educational experts regarding the practical challenges of implementation. Expectations of improved assessment and feedback highlight the need for both residents and attending physicians to be equipped in these domains. Consequently, faculty development and clear communication will be crucial aspects of successful transitioning to CBME.

Objective: To assess the quality of narrative feedback given to surgical residents during the first 5 years of competency-based medical education implementation. Background: Competency-based medical education requires ongoing formative assessments and feedback on learners’ performance. Methods: We conducted a retrospective cross-sectional study using assessments of entrustable professional activities (EPAs) in the Surgical Foundations curriculum at Queen’s University from 2017 to 2022. Two raters independently evaluated the quality of narrative feedback using the Quality of Assessment of Learning score (0–5). Results: A total of 3900 EPA assessments were completed over 5 years. Of assessments, 57% (2229/3900) had narrative feedback documented with a mean Quality of Assessment of Learning score of 2.16 ± 1.49. Of these, 1614 (72.4%) provided evidence about the resident’s performance, 951 (42.7%) provided suggestions for improvement, and 499/2229 (22.4%) connected suggestions to the evidence. There was no meaningful change in narrative feedback quality over time (r = 0.067, P = 0.002). Variables associated with lower quality of narrative feedback include: attending role (2.04 ± 1.48) compared with the medical student (3.13 ± 1.12, P < 0.001) and clinical fellow (2.47 ± 1.54, P < 0.001), concordant specialties between the assessor and learner (2.06 ± 1.50 vs 2.21 ± 1.49, P = 0.025), completion of the assessment 1 month or more after the encounter versus 1 week (1.85 ± 1.48 vs 2.23 ± 1.49, P < 0.001), and resident entrusted versus not entrusted to perform the assessed EPA (2.13 ± 1.45 vs 2.35 ± 1.66; P = 0.008). The quality of narrative feedback was similar for assessments completed under direct and indirect observation (2.18 ± 1.47 vs 2.06 ± 1.54; P = 0.153). Conclusions: Just over half of the EPA assessments of surgery residents contained narrative feedback with overall fair quality. There was no meaningful change in the quality of feedback over 5 years. These findings prompt future research and faculty development.

Background: The optimal treatment of older patients with a displaced femoral neck fracture remains a controversial topic. This study aimed to compare clinical outcomes across a matched group of patients with a femoral neck fracture treated with either hemiarthroplasty or total hip arthroplasty (THA). Methods: Routinely collected health-care databases were linked to create a population-based cohort of 49,597 patients ≥60 years old from Ontario, Canada, who underwent hemiarthroplasty or THA for a femoral neck fracture between 2002 and 2017. A propensity-score-matched cohort was created using relevant and available predictors of treatment assignment and outcomes of interest. Clinical outcomes consisting of hip dislocation, revision surgery, hospital readmission, and death were compared in the matched cohort using survival analysis. Results: Over 99% of THA patients (4,612) were adequately matched 1:1 to hemiarthroplasty patients (total matched cohort = 9,224). Patients treated with THA were at higher risk for hip dislocation at 30 days and 1 and 2 years postoperatively (2-year risk, 1.8% for THA versus 0.8% for hemiarthroplasty; p < 0.001). There was no difference in the short-term (30-day) or long-term (up to 10-year) risk of revision surgery between treatment groups. There was no significant difference in the risk of 30-day hospital readmission between groups. The risk of death at 1 year and 2 years postoperatively was lower for patients treated with THA. Conclusions: For patients with a hip fracture, shared decision-making should involve discussion of the potential higher risk of short-term hip dislocation after THA compared with hemiarthroplasty. The risk of revision surgery was similar between treatment groups at up to 10 years of follow-up. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Aims: This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. Methods: We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. Results: Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. Conclusion: The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients. Cite this article: Bone Joint J 2023;105-B(2):180–189.