Internal Medicine

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of patient visit

1. ●new patient
2. ●focused follow-up

Medical Expert

• □ME 2.2 Elicit an accurate, relevant history
• □ME 2.2 Perform a physical exam that informs the diagnosis
• □ME 2.2 Synthesize patient information from the clinical assessment for the purpose of written or oral summary to a supervisor
• □ME 2.4 Identify and/or monitor key clinical features in the implementation of a management plan

Communicator

• □COM 1.1 Communicate using a patient-centred approach that encourages patient trust and autonomy and is characterized by empathy, respect, and compassion
• □COM 2.1 Conduct a patient-centered interview
• □COM 5.1 Maintain accurate and up-to-date problem lists and medication lists
• □COM 5.1 Document the essential elements of a clinical encounter using a structured approach
• □COM 5.1 Present findings to supervisor
• □COM 5.1 Document relevant patient care orders

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of observation

1. ●direct
2. ●indirect

Presentation

1. ●acute respiratory distress
2. ●hemodynamic instability
3. ●altered level of consciousness
4. ●other

Setting

1. ●clinical
2. ●simulation

Observer role

1. ●staff
2. ●senior resident
3. ●fellow

Medical Expert

• □ME 1.1 Demonstrate compassion for patients
• □ME 1.4 Perform a focused history and physical exam
• □ME 1.4 Recognize urgent problems that may need the involvement of more experienced physicians and seek their assistance
• □ME 1.5 On the basis of patient-centred priorities, seek assistance to prioritize multiple competing tasks that need to be addressed
• □ME 2.1 Address primary priorities of resuscitation (Airway, Breathing, Circulation)
• □ME 2.4 Develop and implement initial management plans for common acute unstable presentations in Internal Medicine
• □ME 3.4 Perform the skills of Advanced Cardiac Life Support (ACLS)

Communicator

• □COM 3.1 Provide explanations and updates to the patient and family

Collaborator

• □COL 3.2 Provide specific information required for safe and effective handover to senior colleagues

Professional

• □P 1.1 Consistently prioritize the needs of patients and others to ensure a patient’s legitimate needs are met

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of observation

1. ●direct
2. ●indirect

Location of patient visit

1. ●emergency department
2. ●ward

Case mix

1. ●chest pain
2. ●shortness of breath
3. ●altered level of consciousness
4. ●fever
5. ●hemodynamic instability
6. ●other

Medical Expert

• □ME 1.1 Demonstrate compassion for patients
• □ME 1.3 Apply clinical and biomedical sciences to manage common patient presentations in Internal Medicine
• □ME 1.4 Recognize urgent problems that may need the involvement of more experienced physicians and seek their assistance
• □ME 1.4 Perform complete and appropriate assessments of patients with common acute medical presentations
• □ME 2.1 Iteratively establish priorities as the patient’s situation evolves
• □ME 2.2 Generate differential diagnoses along with appropriate diagnostic strategies
• □ME 2.2 Complete patient admission as appropriate
• □ME 2.4 Develop and implement initial management plans for common internal medicine presentations
• □ME 3.1 Describe to patients common procedures or therapies for common conditions in Internal Medicine
• □ME 3.2 Obtain informed consent for commonly performed procedures and therapies
• □ME 3.3 Consider urgency, and potential for deterioration, in advocating for the timely execution of a procedure or therapy
• □ME 3.4 Seek assistance, as needed, when unanticipated findings or changing clinical circumstances are encountered

Communicator

• □COM 3.1 Communicate the diagnosis, prognosis and plan of care in a clear, compassionate, respectful and accurate manner
• □COM 4.3 Answer questions from the patient and family about next steps
• □COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions

Collaborator

• □COL 1.1 Receive and appropriately respond to input from other health care professionals
• □COL 3.1 Identify patients requiring handover to other physicians or health care professionals

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Category of main condition

1. ●Cardio (arrhythmia, congestive heart failure, coronary artery disease/chest pain/acute coronary syndrome)
2. ●Endocrine (diabetes mellitus)
3. ●Geriatrics (falls)
4. ●Haem (venous thromboembolic disease, anemia)
5. ●GI (nausea/vomiting, abdominal pain, gastrointestinal bleeding, cirrhosis/jaundice)
6. ●Infectious (fever, sepsis)
7. ●Nephro (acute kidney injury)
8. ●Neuro (delirium/altered level of consciousness, cerebrovascular accident)
9. ●Respiratory (chronic obstructive pulmonary disease/asthma, pneumonia, shortness of breath, hemoptysis)
10. ●other (toxidromes)

Medical Expert

• □Part A: ME 1.1 Demonstrate compassion for patients
• □Part A: ME 1.3 Apply clinical and biomedical sciences to manage common patient presentations in Internal Medicine
• □Part A: ME 1.4 Perform appropriate clinical assessments throughout the course of a patient illness
• □Part A: ME 1.5 On the basis of patient-centred priorities, seek assistance to prioritize multiple competing tasks that need to be addressed
• □Part A: ME 2.1 Iteratively establish priorities as the patient’s situation evolves
• □Part A: ME 2.4 Develop and implement initial management plans for common problems in Internal Medicine
• □Part A: ME 2.4 Adapt the management plans to the clinical course
• □Part A: ME 3.4 Seek assistance as needed when unanticipated findings or changing clinical circumstances are encountered
• □Part A: ME 4.1 Ensure follow-up on results of investigation and response to treatment
• □Part A: ME 4.1 Monitor patients for complications, response to therapy, and evolution of the clinical course
• □Part B: ME 2.3 Work with patients and their families to understand relevant options for care

Communicator

• □Part A: COM 1.2 Optimize the physical environment for patient comfort, privacy, engagement, and safety
• □Part A: COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions
• □Part B: COM 2.1 Integrate and synthesize information about the patient’s beliefs, values, preferences, context and expectations with biomedical and psychosocial information
• □Part B: COM 2.3 Seek and synthesize relevant information from other sources, including the patient’s family, with the patient’s consent
• □Part B: COM 3.1 Provide information on the results of clinical assessments, diagnostic testing, and treatment plans
• □Part B: COM 3.1 Use strategies to verify and validate the understanding of the patient and family
• □Part B: COM 4.1 Explore the perspectives of the patient and others when developing care plans
• □Part B: COM 4.3 Answer questions from the patient and family about next steps

Collaborator

• □Part C: COL 3.1 Identify patients requiring handover to other physicians or health care professionals
• □Part C: COL 3.2 Summarize the patient’s issues, including plans to deal with ongoing issues
• □Part C: COL 3.2 Communicate with the receiving physicians or health care professionals during transitions in care, clarifying issues as needed
• □Part C: COL 3.2 Provide anticipatory guidance for results of outstanding investigations and/or next steps for management

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Role of observer

1. ●supervisor
2. ●physician specialist being consulted
3. ●other health professional

Setting

1. ●ambulatory care
2. ●inpatient
3. ●emergency department

Medical Expert

• □ME 1.5 On the basis of patient-centred priorities, seek assistance to prioritize multiple competing tasks that need to be addressed
• □ME 1.6 Recognize limits in abilities and scope of practice, and consult specialists and/or other health care professionals when needed
• □ME 4.1 Develop and prioritize well defined questions to be addressed with a consultant or other health care professional
• □ME 2.4 Incorporate consultant recommendations into diagnostic and treatment plans
• □ME 4.1 Coordinate investigation, treatment, and follow-up plans when multiple physicians and healthcare professionals are involved
• □ME 4.1 Ensure follow-up on the results of consultation requests and/or recommendations

Communicator

• □COM 5.1 Document information about patients and their medical conditions in a manner that enhances intra- and interprofessional care

Collaborator

• □COL 1.2 Apply knowledge of the roles and scopes of practice of other health care professionals for optimal patient care
• □COL 1.3 Discuss with the patient and family any plan for involving other health care professionals, including other physicians, in the patient’s care

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Complex hospital stay

1. ●yes
2. ●no

Medical Expert

• □Part A: ME 2.2 Synthesize patient information to anticipate complications and challenges for patients transitioning away from the acute care setting
• □Part A: ME 2.4 Generate discharge plans that address patient’s therapeutic needs, disease and treatment monitoring needs, and relevant risk factor reduction
• □Part A: ME 4.1 Ensure follow-up on results of investigation and response to treatment
• □Part A: ME 5.2 Reconcile current and prior medication lists to enhance patient safety
• □Part B: ME 1.1 Demonstrate compassion for patients

Communicator

• □Part A: COM 5.1 Document the admission to adequately convey clinical course and the rationale for decisions
• □Part B: COM 3.1 Provide information to patients and caregivers regarding the discharge plan
• □Part B: COM 4.3 Avoid the use of medical jargon and technical terminology
• □Part B: COM 3.1 Use strategies to verify and validate the understanding of the patient and family
• □Part B: COM 4.3 Answer questions from the patient and family about next steps

Collaborator

• □Part A: COL 1.3 Integrate the patients’ perspective and context into the collaborative care plan
• □Part A: COL 3.2 Communicate with the patient’s primary health care professional about the patient’s care
• □Part A: COL 3.2 Summarize the patient’s issues, including plans to deal with ongoing issues

Health Advocate

• □Part B: HA 1.3 Work with the patient and family to identify opportunities for disease prevention, health promotion, and health protection

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of observation

1. ●direct
2. ●indirect

Presentation

1. ●acute respiratory distress
2. ●hemodynamic instability
3. ●altered level of consciousness
4. ●other

Setting

1. ●emergency department
2. ●step-down unit
3. ●critical care unit
4. ●ward
5. ●simulation

Medical Expert

• □ME 2.1 Recognize medical instability in patients with acute medical conditions
• □ME 2.1 Address primary priorities of resuscitation (Airway, Breathing, Circulation)
• □ME 2.2 Perform a focused clinical assessment of a patient with an unstable medical condition
• □ME 2.2 Develop a specific differential diagnosis relevant to the patient’s presentation
• □ME 2.4 Develop and implement preliminary treatment strategies for patients with unstable medical conditions
• □ME 4.1 Identify the necessity and urgency of referral for advanced care

Communicator

• □COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions

Collaborator

• □COL 3.2 Communicate with the receiving physicians or health care professionals during transitions in care, clarifying issues as needed

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Category

1. ●stable acute condition
2. ●unstable acute condition
3. ●progressive chronic condition

Setting

1. ●ambulatory
2. ●inpatient
3. ●simulation

Substitute decision maker

1. ●yes
2. ●no

Observer role

1. ●staff
2. ●senior resident

Medical Expert

• □ME 2.3 Discuss and clarify previously established advanced directives and goals or care
• □ME 2.4 Discuss with the patient and family the degree of uncertainty inherent in all clinical situations
• □ME 2.3 Work with patients and their families to understand relevant options for care

Communicator

• □COM 1.6 Identify patients who lack decision-making capacity and seek out their substitute decision maker
• □COM 1.2 Optimize the physical environment for patient comfort, privacy, engagement and safety
• □COM 1.4 Identify, verify and validate non-verbal cues
• □COM 5.1 Document information about patients and their medical conditions in a manner that enhances intra- and interprofessional care

Professional

• □P 3.1 Adhere to institutional policies and procedures relevant to advance directives and goals of care
• □P 3.1 Apply the laws governing substitute decision making

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Scholar

• □S 1.2 Seek and respond to feedback on performance in the clinical setting
• □S 1.2 Identify learning needs that arise in daily work
• □S 1.1 Create a plan to address identified learning needs
• □S 3.1 Generate focused questions that address practice uncertainty and knowledge gaps
• □S 3.2 Select appropriate sources of evidence for a given practice-related question
• □S 3.3 Interpret the evidence, including a critique of the relevance to practice
• □S 3.4 Integrate the evidence into a solution for the identified learning need

Professional

• □P 2.1 Demonstrate a commitment to improving one’s own performance

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of observation

1. ●direct
2. ●indirect

Setting

1. ●ambulatory care
2. ●inpatient

Medical Expert

• □ME 1.5 Maintain a duty of care and patient safety while balancing multiple responsibilities
• □ME 2.1 Consider clinical urgency and comorbidities in determining priorities to be addressed
• □ME 2.2 Perform complete and appropriate assessment of complex clinical presentations, including consideration of competing treatment needs
• □ME 2.2 Select and interpret appropriate investigations based on a differential diagnosis
• □ME 2.2 Integrate and summarize information obtained through the clinical assessment and investigations
• □ME 2.2 Generate and prioritize the differential diagnoses
• □ME 2.2 Monitor the evolution of the clinical course and/or the patient’s response to treatment
• □ME 2.4 Generate management plans that address on-going diagnostic uncertainty, address treatment needs, evolve with the clinical course, and incorporate best practice and evidence-based guidelines
• □ME 3.1 Integrate all sources of information to develop a procedural or therapeutic plan that is safe, patient-centred, and considers the risks and benefits of all approaches
• □ME 4.1 Establish plans for ongoing care, taking into consideration the patient’s clinical state, circumstances, preferences, and actions, as well as available resources, best practices, and research evidence
• □ME 4.1 Determine the necessity and timing of referral to another health care professional

Communicator

• □COM 3.1 Provide information to patients and their families clearly and compassionately
• □COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions

Collaborator

• □COL 1.2 Work effectively with other health care professionals, including other physicians

Leader

• □L 2.1 Demonstrate resource stewardship in clinical care

Scholar

• □S 3.1 Generate focused clinical questions relevant to patient diagnoses or management to guide literature searches
• □S 3.2 Utilize point of care evidence-based resources
• □S 3.4 Critically appraise relevant medical literature to make evidence informed medical decisions

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Condition

1. ●asthma
2. ●anemia
3. ●arthritis
4. ●cancer
5. ●chronic fatigue
6. ●chronic kidney disease
7. ●chronic obstructive pulmonary disease
8. ●congestive heart failure
9. ●connective tissue disease
10. ●coronary artery disease
11. ●cirrhosis
12. ●dementia
13. ●diabetes mellitus
14. ●hypertension
15. ●other

Setting

1. ●ambulatory care
2. ●inpatient

Medical Expert

• □Part A: ME 1.4 Perform clinical assessments that address all relevant issues
• □Part A: ME 2.1 Consider clinical urgency and comorbidities in determining priorities to be addressed
• □Part A: ME 2.2 Select and interpret investigations based on clinical priorities
• □Part A: ME 2.2 Integrate and summarize information obtained through the clinical assessment and investigations
• □Part A: ME 2.4 Identify and address interactions between different diseases and different treatments
• □Part A: ME 2.4 Develop patient-centered management plans that address multimorbidity, frailty and/or complexity of patient presentations
• □Part A: ME 2.4 Adapt guideline-based recommendations for care to the context of the patient’s specific needs and priorities
• □Part A: ME 4.1 Determine the necessity and timing of referral to another health care professional
• □Part A: ME 4.1 Establish plans for ongoing care
• □Part B: ME 2.3 Establish goals of care in collaboration with the patient and family

Communicator

• □Part A: COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions
• □Part A: COM 5.1 Adapt record keeping to the specific guidelines of their discipline and the clinical context
• □Part B: COM 1.6 Adapt communication to the unique needs and preferences of the patient
• □Part B: COM 3.1 Provide information to patients and their families clearly and compassionately
• □Part B: COM 3.1 Provide explanations that are clear and accurate while checking for understanding
• □Part B: COM 4.3 Use communication skills and strategies that help the patient make informed decisions

Collaborator

• □Part A: COL 1.2 Work effectively with other health care professionals, including other physicians

Leader

• □Part A: L 2.1 Demonstrate resource stewardship in clinical care

Health Advocate

• □Part A: HA 1.1 Facilitate timely patient access to services and resources
• □Part B: HA 1.1 Recognize potential barriers to comprehension and learning such as illness, literacy and language skills
• □Part B: HA 1.2 Select patient education resources
• □Part B: HA 1.2 Work with the patient to increase opportunities to adopt healthy behaviours

Scholar

• □Part A: S 3.4 Integrate best evidence and clinical expertise into decision-making

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Case mix

1. ●perioperative
2. ●obstetrical medicine
3. ●other clinical service

Setting

1. ●ambulatory
2. ●inpatient

Medical Expert

• □Part A: ME 1.4 Perform clinical assessments that address all relevant issues
• □Part A: ME 2.1 Identify relevant clinical issues in a consultation request
• □Part A: ME 2.2 Perform focused clinical assessments without missing key elements
• □Part A: ME 2.4 Develop recommendations for management that address the consult question and consider the patient’s status and other health problems
• □Part A: ME 4.1 Determine the necessity and timing of referral to another health care professional
• □Part B: ME 2.2 Synthesize and interpret information from the clinical assessment
• □Part C: ME 2.1 Identify the need and timeliness for communication with referring physicians
• □Part C: ME 2.2 Synthesize and interpret information from the clinical assessment

Communicator

• □Part B: COM 5.1 Organize information in appropriate sections
• □Part B: COM 5.1 Document all relevant findings and investigations
• □Part B: COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions
• □Part B: COM 5.1 Provide a clear plan for ongoing management
• □Part B: COM 5.1 Adapt the written consultation to the clinical context

Collaborator

• □Part A: COL 1.2 Establish a clear agreement with the referring physician about roles and responsibilities regarding ongoing care
• □Part B: COL 1.3 Provide written documentation in a timely manner
• □Part B: COL 1.3 Share expertise when acting in the consultant role, using referral as an opportunity to improve quality of care
• □Part C: COL 1.3 Share expertise when acting in the consultant role, using referral as an opportunity to improve quality of care
• □Part C: COL 1.3 Use effective oral communication strategies with physicians and other colleagues in the health care professions

Scholar

• □Part A: S 3.4 Integrate best evidence and clinical expertise into decision-making

Professional

• □Part A: P 1.1 Respect the boundaries of the consultative role within the care of the patient
• □Part C: P 1.1 Respect the boundaries of the consultative role within the care of the patient

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Presentation

1. ●shock
2. ●systemic inflammatory response syndrome/sepsis
3. ●acute respiratory distress
4. ●unstable cardiac rhythms
5. ●acute coronary syndrome
6. ●seizures/altered level of consciousness

Medical Expert

• □Part A: ME 1.5 Prioritize patients on the basis of clinical presentations
• □Part A: ME 1.6 Seek assistance in situations that are complex or new
• □Part A: ME 2.2 Focus the assessment, performing in a time-effective manner without excluding key elements
• □Part A: ME 2.2 Select and interpret investigations based on clinical priorities
• □Part A: ME 2.2 Synthesize patient information to determine differential diagnosis
• □Part A: ME 2.3 Address the impact of the medical condition on the patient’s ability to pursue life goals and purposes
• □Part A: ME 2.3 Recognize when ongoing resuscitation efforts are no longer effective and should be discontinued
• □Part A: ME 2.4 Develop and implement focused treatment strategies
• □Part A: ME 2.4 Manage hemodynamic support, non-invasive ventilation, and monitoring
• □Part A: ME 2.4 Develop a plan to deal with clinical uncertainty
• □Part A: ME 3.1 Integrate planned procedures of therapies into global assessment and management plans
• □Part A: ME 3.3 Triage a procedure or therapy, taking into account clinical urgency, potential for deterioration, and available resources
• □Part A: ME 3.4 Competently perform resuscitation protocols
• □Part A: ME 4.1 Determine the necessity and timing of referral to another health care professional

Communicator

• □Part A: COM 1.5 Recognize when strong emotions (such as anger, fear, anxiety, or sadness) are impacting an interaction and respond appropriately
• □Part A: COM 1.5 Establish boundaries as needed in emotional situations
• □Part A: COM 3.1 Provide information to patients and their families clearly and compassionately

Collaborator

• □Part A: COL 3.2 Organize the handover of care to the most appropriate physician or health care professional
• □Part B: COL 1.2 Work effectively as a member of a resuscitation team
• □Part B: COL 2.1 Delegate tasks and responsibilities in an appropriate and respectful manner
• □Part B: COL 1.3 Apply closed loop communication in urgent or crisis situations to work effectively with physicians and other colleagues in the health care professions
• □Part B: COL 3.2 Organize the handover of care to the most appropriate physician or health care professional

Leader

• □Part A: L 4.2 Lead resuscitation teams delivering Acute Cardiac Life Support or care directed at other unstable medical conditions
• □Part B: L 4.2 Establish clear leadership in resuscitative efforts, assuming the leadership role as appropriate

Professional

• □Part B: P 4.1 Maintain capacity for professional clinical performance in stressful situations

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●clinical
2. ●simulation

Procedure

1. ●airway management & endotracheal intubation
2. ●arterial line catheter insertion
3. ●central line placement
4. ●thoracentesis
5. ●paracentesis
6. ●lumbar puncture
7. ●joint arthrocentesis

Site

1. ●not applicable
2. ●femoral
3. ●internal jugular
4. ●subclavian
5. ●knee
6. ●other joint

Use of ultrasound guidance

1. ●yes
2. ●no

Medical Expert

• □ME 3.2 Obtain and document informed consent, explaining the risks and benefits of, and the rationale for, a proposed procedure
• □ME 3.4 Perform pre-procedural tasks in a timely, skilful, and safe manner - Establish and maintain a sterile field - Maintain universal precautions - Handle sharps safely - Hand-cleanse, gown and glove
• □ME 3.4 Perform procedures in a skilful and safe manner, adapting to unanticipated findings or changing clinical circumstances
• □ME 3.4 Document procedures accurately
• □ME 3.4 Establish and implement a plan for post-procedure care
• □ME 3.4 Recognize and manage complications

Communicator

• □COM 5.1 Document the encounter to convey the procedure and outcome

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of observation

1. ●direct
2. ●indirect

Observer type

1. ●faculty/staff
2. ●senior resident

Category

1. ●patient leaving hospital against medical advice
2. ●patient refusing recommended treatment
3. ●patient or substitute decision maker refusing recommended home supports or nursing home placement
4. ●other

Medical Expert

• □ME 2.3 Determine the patient’s understanding of their condition, risks associated with treatment options and alternatives to proposed treatments
• □ME 2.2 Assess the patient’s capacity to make decisions about his/her medical care
• □ME 4.1 Determine the necessity and appropriate timing of consultation with mental health and/or other professionals

Communicator

• □COM 1.6 Tailor approaches to decision-making to patient capacity, values, and preferences
• □COM 1.5 Recognize when strong emotions (such as anger, fear, anxiety, or sadness) are impacting an interaction and respond appropriately
• □COM 1.3 Recognize when one’s own values, biases, or perspectives may have an impact on the quality of care, and modify the approach to the patient accordingly
• □COM 2.1 Actively listen and respond to patient cues
• □COM 3.1 Convey information related to the patient’s health status, care, and needs in a timely, honest, and transparent manner
• □COM 4.1 Facilitate discussions with the patient and family in a way that is respectful, non-judgmental, and culturally safe

Professional

• □P 3.1 Adhere to institutional policies and procedures relevant to advance directives and goals of care
• □P 3.1 Apply professional standards, and laws governing capacity and competence for medical decision making

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Complexity

1. ●low
2. ●medium
3. ●high

Substitute decision maker

1. ●yes
2. ●no

Issue

1. ●futility of care
2. ●breaking bad news
3. ●discharge related discussion
4. ●conflicting recommendations of consultants

Observer

1. ●staff
2. ●senior resident
3. ●other health care professional

Medical Expert

• □ME 4.1 Establish plans for ongoing care

Communicator

• □COM 3.1 Provide information on diagnosis and/or prognosis clearly and compassionately
• □COM 1.5 Recognize when strong emotions (such as anger, fear, anxiety, or sadness) are impacting an interaction and respond appropriately
• □COM 1.5 Establish boundaries as needed in emotional situations
• □COM 1.6 Tailor approaches to decision-making to patient capacity, values, and preferences
• □COM 2.2 Manage the flow of challenging patient encounters, including those with angry, distressed, or excessively talkative individuals
• □COM 4.1 Communicate with cultural awareness and sensitivity
• □COM 4.3 Use communication skills and strategies that help the patient make informed decisions

Collaborator

• □COL 1.2 Determine the necessity of involving other health care professionals, and incorporate their perspectives as appropriate

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●clinical
2. ●simulation

Type of event

1. ●error
2. ●near miss
3. ●adverse event

Disclosure observed

1. ●yes
2. ●no

Medical Expert

• □ME 1.4 Perform clinical assessments that address the breadth of issues in each case
• □ME 5.1 Identify the clinical circumstances contributing to an adverse event
• □ME 5.1 Intervene to mitigate further injury
• □ME 5.1 Identify changes in practice/clinical care to prevent similar events
• □ME 5.1 Report patient safety incidents to appropriate institutional representatives

Communicator

• □COM 3.2 Communicate the reasons for unanticipated clinical outcomes to the patients and disclose patient safety incidents
• □COM 3.2 Apologize appropriately for a harmful patient safety incident

Professional

• □P 4.1 Apply strategies to mitigate the personal impact of patient safety incidents

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●ambulatory
2. ●inpatient
3. ●simulation

Scenario

1. ●cancer
2. ●organ failure
3. ●neurodegenerative diseases

Medical Expert

• □Part A: ME 1.6 Adapt care as the complexity, uncertainty, and ambiguity of the patient’s clinical situation evolves
• □Part A: ME 1.6 Seek assistance in situations that are complex or new
• □Part A: ME 2.2 Identify symptoms influencing patient comfort at the end of life
• □Part A: ME 2.2 Synthesize patient information to determine symptom management priorities
• □Part A: ME 2.4 Develop and implement management plans
• □Part A: ME 4.1 Establish plans for ongoing care, taking into consideration the patient’s clinical state, circumstances, preferences, and actions, as well as available resources, best practices, and research evidence
• □Part A: ME 4.1 Determine the necessity and timing of referral to another health care professional
• □Part B: ME 2.3 Share concerns, in a constructive and respectful manner, with patients and their families about their goals of care when they are not felt to be achievable
• □Part B: ME 2.3 Establish goals of care in collaboration with the patient and family

Communicator

• □Part A: COM 2.1 Actively listen and respond to patient cues
• □Part B: COM 1.3 Recognize when the values, biases, or perspectives of patients, physicians, or other health care professionals, may have an impact on the quality of care, and modify the approach to the patient accordingly
• □Part B: COM 1.4 Respond to patients’ non-verbal communication and use appropriate non- verbal behaviours to enhance communication with patients
• □Part B: COM 1.5 Recognize when strong emotions (such as anger, fear, anxiety, or sadness) are impacting an interaction and respond appropriately
• □Part B: COM 1.5 Establish boundaries as needed in emotional situations
• □Part B: COM 2.2 Manage the flow of challenging patient encounters, including those with angry, distressed, or excessively talkative individuals
• □Part B: COM 3.1 Provide information to patients and their families clearly and compassionately
• □Part B: COM 3.1 Provide information related to progression of illness and evolution of care
• □Part B: COM 3.1 Educate patients and caregivers about end of life care options including palliative care and medical assistance in dying
• □Part B: COM 4.1 Facilitate discussions with the patient and family in a way that is respectful, non-judgmental, and culturally safe
• □Part B: COM 4.3 Answer questions from the patient and family about next steps
• □Part B: COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions

Collaborator

• □Part A: COL 1.2 Consult as needed with other health care professionals, including other physicians

Health Advocate

• □Part A: HA 1.1 Facilitate timely patient access to services and resources
• □Part B: HA 1.1 Facilitate timely patient access to services and resources

Professional

• □Part A: P 4.1 Maintain capacity for professional clinical performance in stressful situations treatment

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Condition

1. ●asthma/COPD
2. ●cancer screening in at risk populations
3. ●diabetes
4. ●falls/frailty
5. ●immunocompromised patient
6. ●medication reviews
7. ●vaccinations
8. ●vascular risk reduction
9. ●other

Medical Expert

• □ME 1.1 Demonstrate compassion for patients
• □ME 1.4 Perform clinical assessments that address the breadth of issues in each case
• □ME 2.2 Assess risk factors for disease progression as well as a patient’s need for health promotion and/or health surveillance
• □ME 2.2 Identify a patient’s relevant determinants of health
• □ME 2.4 Integrate primary and secondary prevention strategies as part of the overall management plan

Communicator

• □COM 1.4 Respond to patients’ non-verbal communication and use appropriate non- verbal behaviours to enhance communication with patients
• □COM 1.5 Recognize when strong emotions (such as anger, fear, anxiety, or sadness) are impacting an interaction and respond appropriately
• □COM 2.1 Actively listen and respond to patient cues
• □COM 3.1 Convey information related to the patient’s health status, care, and needs in a timely, honest, and transparent manner

Health Advocate

• □HA 1.1 Facilitate timely patient access to services and resources
• □HA 1.2 Apply the principles of behaviour change during conversations with patients about adopting healthy behaviours
• □HA 1.2 Counsel and support patients regarding risk factor reduction, such as smoking cessation
• □HA 1.3 Work with the patient and/or family to identify opportunities for disease prevention, health promotion and health protection
• □HA 1.3 Evaluate with the patient the potential benefits and harms of health screening

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Complexity of case load

1. ●low
2. ●medium
3. ●high

Medical Expert

• □Part B: ME 1.5 Carry out professional duties in the face of multiple competing demands

Collaborator

• □Part B: COL 2.1 Delegate tasks and responsibilities in an appropriate and respectful manner
• □Part B: COL 2.1 Show respect toward collaborators
• □Part B: COL 2.2 Implement strategies to promote understanding, manage differences, and resolve conflicts in a manner that supports a collaborative culture

Leader

• □Part B: L 4.1 Integrate supervisory and teaching responsibilities into the overall management of the clinical service
• □Part B: L 4.1 Manage time and prioritize tasks
• □Part B: L 4.1 Demonstrate efficiency and effectiveness in running the physician team

Scholar

• □Part A: S 2.1 Recognize the influence of role-modelling and the impact of the formal, informal, and hidden curriculum on learners
• □Part A: S 2.2 Ensure a safe learning environment for all members of the team
• □Part A: S 2.3 Supervise learners to ensure they work within their limits, seeking guidance and supervision when needed
• □Part A: S 2.3 Balance supervision and graduated responsibility, ensuring the safety of patients and learners
• □Part A: S 2.4 Plan and deliver a learning activity
• □Part A: S 2.4 Provide clinical teaching and/or other informal learning activities
• □Part A: S 2.5 Provide feedback to enhance learning and performance
• □Part A: S 2.6 Assess and evaluate learners, teachers, and programs in an educationally appropriate manner
• □Part B: S 2.1 Use strategies for deliberate, positive role-modelling
• □Part B: S 2.2 Ensure a safe learning environment for all members of the team
• □Part B: S 2.3 Supervise learners to ensure they work within their limits, providing guidance and supervision when needed
• □Part B: S 2.3 Balance supervision and graduated responsibility, ensuring the safety of patients and learners

Professional

• □Part A: P 1.1 Intervene when behaviours toward learners undermine a respectful environment
• □Part A: P 3.3 Participate in the assessment of junior learners
• □Part B: P 1.1 Seek guidance for teaching and team management when needed

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □Part A: ME 1.5 Carry out professional duties in the face of multiple, competing demands
• □Part A: ME 1.4 Perform relevant and time-effective clinical assessments
• □Part A: ME 3.1 Determine the most appropriate procedures or therapies for the purpose of assessment and/or management
• □Part A: ME 2.4 Establish patient centered management plans
• □Part A: ME 4.1 Coordinate investigation, treatment and followup when multiple physicians and health care professionals are involved
• □Part A: ME 4.1 Formulate and implement plans for discharge that include appropriate ongoing care, arrangements for relevant community support services and followup on investigations
• □Part A: ME 5.2 Use systems to track and follow-up on clinical data such as investigations and laboratory tests

Communicator

• □Part A: COM 5.1 Document clinical encounters in an accurate, complete, timely and accessible manner
• □Part B: COM 1.5 Manage disagreements and emotionally charged conversations with patients and/or families

Collaborator

• □Part A: COL 1.3 Use referral and consultation as opportunities to improve quality of care
• □Part A: COL 3.2 Demonstrate safe handover of care during patient transition out of the hospital setting
• □Part B: COL 1.2 Make effective use of the scope and expertise of other health care professionals
• □Part B: COL 1.1 Respond appropriately to input from other health care professionals
• □Part B: COL 1.3 Communicate effectively with physicians and other colleagues in the health care professions
• □Part B: COL 2.1 Show respect toward collaborators

Leader

• □Part A: L 2.1 Allocate health care resources for optimal patient care
• □Part A: L 4.1 Manage time and prioritize tasks

Health Advocate

• □Part B: HA 1.1 Facilitate timely patient access to services and resources

Scholar

• □Part A: S 3.4 Integrate best evidence and clinical expertise into decision-making

Professional

• □Part B: P 1.1 Respond punctually to requests from patients or other health care professionals
• □Part B: P 1.1 Exhibit appropriate professional behaviours

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of clinic

1. ●general IM
2. ●focused
3. ●general subspecialty

Medical Expert

• □Part A: ME 1.4 Perform relevant and time-effective clinical assessments
• □Part A: ME 2.2 Select investigation strategies demonstrating awareness of availability and access in the outpatient setting
• □Part A: ME 2.4 Establish a patient-centered management plan
• □Part A: ME 2.4 Formulate treatment plans that are suitable for implementation in the outpatient setting
• □Part A: ME 4.1 Coordinate investigation, treatment and followup when multiple physicians and health care professionals are involved
• □Part B: ME 5.2 Use systems to track and follow-up on clinical data, such as studies and laboratory tests

Communicator

• □Part A: COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions

Collaborator

• □Part A: COL 1.3 Use referral and consultation as opportunities to improve quality of care and patient safety
• □Part A: COL 1.3 Provide accurate, timely and relevant written information to the referring/primary care physician
• □Part A: COL 1.3 Address the questions and concerns of the referring/primary care physician when acting in the consultant role
• □Part B: COL 1.2 Make effective use of the scope and expertise of other health care professionals
• □Part B: COL 1.1 Respond appropriately to input from other health care professionals
• □Part B: COL 1.3 Communicate effectively with physicians and other colleagues in the health care professions
• □Part B: COL 2.1 Delegate tasks and responsibilities in an appropriate and respectful manner

Leader

• □Part A: L 2.1 Allocate health care resources for optimal patient care
• □Part B: L 4.1 Manage time effectively in the ambulatory clinic
• □Part B: L 4.1 Review and act on test results in a timely manner

Scholar

• □Part A: S 3.4 Integrate best evidence and clinical expertise into decision-making

Professional

• □Part A: P 2.2 Adhere to institutional policies and procedures in delivering clinical care
• □Part B: P 1.1 Respond punctually to requests from patients or other health care professionals
• □Part B: P 1.1 Exhibit appropriate professional behaviors

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Setting

1. ●ambulatory
2. ●inpatient

Condition

1. ●acute
2. ●chronic
3. ●both acute and chronic

Type of undifferentiated issue

1. ●limited data
2. ●non-diagnostic data
3. ●conflicting data

Type of observation

1. ●direct observation
2. ●case review
3. ●review of consult note/other documents

Medical Expert

• □ME 2.1 Prioritize which issues need to be addressed
• □ME 2.2 Synthesize patient information
• □ME 2.2 Revise the differential diagnosis in response to new clinical information, or response to treatment
• □ME 2.4 Demonstrate flexibility in clinical reasoning, in the setting of clinical uncertainty
• □ME 2.4 Establish a patient-centered management plan despite limited, non- diagnostic, or conflicting clinical data
• □ME 2.4 Develop a plan to deal with clinical uncertainty
• □ME 3.1 Determine the most appropriate procedures or therapies for the purpose of assessment and/or management
• □ME 4.1 Determine the necessity and timing of referral to another health care professional

Communicator

• □COM 3.1 Convey information related to the uncertainty in diagnosis and/or treatment in a clear, timely and transparent manner
• □COM 4.1 Facilitate discussions with the patient and family in a way that is respectful, non-judgmental, and culturally safe
• □COM 4.3 Use communication skills and strategies that help the patient make informed decisions

Collaborator

• □COL 1.2 Consult as needed with other health care professionals, including other physicians

Professional

• □P 1.1 Identify limits in their own expertise

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Type of observation

1. ●direct
2. ●indirect (e.g. review of documents)

Decision to transfer

1. ●yes
2. ●no

Patient acuity

1. ●ward
2. ●emergency room
3. ●ICU/CCU

Medical Expert

• □ME 2.2 Interpret clinical information gathered by another health professional, along with the results of investigations, for the purposes of diagnosis and management
• □ME 2.4 Determine the setting of care appropriate for the patient’s health needs
• □ME 2.4 Establish a plan for ongoing care in the local setting and/or for care prior to and during transfer

Communicator

• □COM 2.3 Request and synthesize patient information gathered by another health professional

Collaborator

• □COL 3.1 Determine when a patient should be transferred to ensure optimal patient care
• □COL 3.2 Recognize and act on patient safety issues in the transfer of care
• □COL 1.2 Negotiate overlapping and shared responsibilities with physicians and other colleagues in the health care professions

Leader

• □L 2.1 Apply knowledge of the health care resources available in other care settings

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Case complexity

1. ●medium
2. ●high

Type of transfer

1. ●to acute care setting with high resource intensity
2. ●to acute care setting with low resource intensity

Setting

1. ●clinical
2. ●simulation

Medical Expert

• □ME 2.4 Determine the setting of care appropriate for the patient’s health needs
• □ME 4.1 Assess the need, timing, risk and benefits of transferring a patient’s care to another health professional and/or care setting
• □ME 2.4 Anticipate, prevent and manage changes in health status at the time of transition
• □ME 2.4 Establish a plan for ongoing care in the local setting and/or for care prior to and during transfer

Collaborator

• □COL 1.2 Consult as needed with other health care professionals, including other physicians
• □COL 3.1 Organize the handover of care to the most appropriate physician
• □COL 3.2 Summarize the patient’s issues, including plans to deal with ongoing issues
• □COL 3.2 Recognize and act on patient safety issues in the transfer of care

Leader

• □L 2.1 Apply knowledge of the health care resources available in other care settings

Health Advocate

• □HA 1.1 Facilitate timely patient access to services and resources

Professional

• □P 1.1 Keep the patient and family informed of changes in health status, treatment plan and/or setting of care

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Role of observer

1. ●supervisor
2. ●primary care provider
3. ●consulting physician
4. ●other health care professional

Medical Expert

• □ME 2.4 Integrate recommendations from other health care professionals into management plans
• □ME 4.1 Coordinate treatment and follow-up across care settings

Collaborator

• □COL 1.2 Make effective use of the scope and expertise of other health care professionals
• □COL 1.1 Respond appropriately to input from other health care professionals
• □COL 1.3 Communicate effectively with physicians and other colleagues in the health care professions
• □COL 2.2 Negotiate to achieve consensus when there are differences in recommendations provided by other health care professionals

Health Advocate

• □HA 1.1 Facilitate timely patient access to services and resources

Professional

• □P 1.1 Respond punctually to requests from patients or other health care professionals
• □P 1.1 Exhibit appropriate professional behaviors

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 1.6 Recognize and respond to the complexity, uncertainty and ambiguity inherent in medical practice

Leader

• □L 4.2 Adjust educational experiences to gain competencies necessary for future practice

Health Advocate

• □HA 2.3 Identify and respond to unmet health care needs within one’s practice

Scholar

• □S 1.2 Identify opportunities for learning and improvement by reflecting on and assessing performance using various internal and external data sources
• □S 3.1 Generate focused questions that address practice uncertainty and knowledge gaps
• □S 1.1 Identify learning needs to enhance competence across all CanMEDS roles
• □S 1.1 Create and implement a learning plan
• □S 1.1 Develop, implement, monitor and revise a personal learning plan to enhance professional practice

Professional

• □P 2.1 Demonstrate a commitment to maintaining and enhancing competence
• □P 3.1 Fulfil professional standards of practice by participating in programs that record continuing professional development (e.g. Royal College Maintenance of Certification Program)

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 5.1 Identify human and systems factors contributing to patient safety incidents
• □ME 5.2 Adopt strategies that promote patient safety and address human and system factors

Leader

• □L 1.1 Participate in a patient safety or quality improvement initiative
• □L 1.3 Analyze harmful patient safety incidents and near misses
• □L 1.3 Employ a systems-based approach to develop solutions for quality improvement and patient safety issues

Scholar

• □S 3.3 Critically evaluate the integrity, reliability, and applicability of health-related research and literature

Professional

• □P 3.1 Respond to, cope with, and constructively learn from a complaint
• □P 4.3 Support colleagues in mitigating the impact of patient safety incidents on personal wellbeing, and responding to these incidents as opportunities for practice improvement

Case description

Feedback provided

Next steps