Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members' perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team's collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams' delivery of care for the complex, chronically ill.

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To the Editor P values are often misused and misinterpreted in the medical literature. Common mistakes include assuming P values measure the probability of a hypothesis being true (ie, indicate uncertainty) and quantify the strength of an observed effect (ie, conflating small P values with true effects). 1 As a solution, Tignanelli et al 2 strongly recommend the use of the Fragility Index (FI) and Fragility Quotient (FQ) in the reporting and appraisal of surgical randomized clinical trials (RCTs).While we agree that it is problematic to use a threshold P value of .05 in evaluating results of RCTs, the FI/FQ is not the solution for several reasons. First, as previously demonstrated, the FI almost perfectly correlates, albeit inversely, with the P value. 3 As a result, comparisons with larger P values (closer to .05) will be categorized as fragile while comparisons with smaller P values (eg, P < .001) will be deemed robust. This language is misleading, as it is widely accepted that P values should not be interpreted as a measure of the strength of an effect. 1 Any effect, no matter how small, can produce a small P value if the sample size is large enough, and large effects may produce unimpressive P values if the sample size is small. Similarly, the FI is a function of the sample size. 3 Randomized clinical trials with larger sample sizes are less likely to have a small FI. To address this issue, Tignanelli et al 2 present the FQ, which is obtained by dividing the FI by the sample size. 4 However, the authors provide no guidance for the interpretation of FQ values, which are less intuitive than the FI. Moreover, the FI is also correlated with the event rate of the outcome of interest. By virtue of this, results for outcomes with low event rates (eg, mortality) will be fragile, even when effects might be clinically meaningful. Lastly, the FI is at odds with the principles of RCT design. To conserve resources and minimize potential harm to patients, superiority RCTs are carefully designed to recruit the fewest patients necessary to detect a minimal clinically important difference. Considering these worthy objectives, it is unsurprising that many RCTs demonstrate fragility. Alternative solutions to improve the appraisal of surgical RCTs include the use of confidence intervals, as these may more directly indicate the size of an effect and its associated uncertainty, 1 and the interpretation of the observed differences in the context of absolute estimates and measures of clinical significance, such as minimal clinically important differences.

In this population-based analysis, the rate of surgical procedures decreased during the COVID period with hospitals rapidly reducing ambulatory and in-patient elective procedures in response to government directives. However, the observed and unexpected large reduction in urgent surgical procedures highlights the need to prioritize access to care for patients with emergency surgical conditions as part of pandemic planning.

Background The incidence of colorectal cancer is rising in adults <50 years of age. As a primarily unscreened population, they may have clinically important delays to diagnosis and treatment. This study aimed to review the literature on delay intervals in patients <50 years with colorectal cancer (CRC), and explore associations between longer intervals and outcomes. Methods MEDLINE, Embase, and LILACS were searched until December 2, 2021. We included studies published after 1990 reporting any delay interval in adults <50 with CRC. Interval measures and associations with stage at presentation or survival were synthesized and described in a narrative fashion. Risk of bias was assessed using the Newcastle-Ottawa Scale, Institute of Health Economics Case Series Quality Appraisal Checklist, and the Aarhus Checklist for cancer delay studies. Results 55 studies representing 188,530 younger CRC patients were included. Most studies used primary data collection (64%), and 47% reported a single center. Sixteen unique intervals were measured. The most common interval was symptom onset to diagnosis (21 studies; N = 2,107). By sample size, diagnosis to treatment start was the most reported interval (12 studies; N = 170,463). Four studies examined symptoms onset to treatment start (total interval). The shortest was a mean of 99.5 days and the longest was a median of 217 days. There was substantial heterogeneity in the measurement of intervals, and quality of reporting. Higher-quality studies were more likely to use cancer registries, and be population-based. In four studies reporting the relationship between intervals and cancer stage or survival, there were no clear associations between longer intervals and adverse outcomes. Discussion Adults <50 with CRC may have intervals between symptom onset to treatment start greater than 6 months. Studies reporting intervals among younger patients are limited by inconsistent results and heterogeneous reporting. There is insufficient evidence to determine if longer intervals are associated with advanced stage or worse survival. Other This study’s protocol was registered with the Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020179707).

Background: Urinary catheters are placed after rectal surgery to prevent urinary retention, but prolonged use may increase the risk of urinary tract infection (UTI). This review evaluated the non-inferiority of early urinary catheter removal compared with late removal for acute urinary retention risk after rectal surgery. Methods: MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched from January 1980 to February 2019. RCTs comparing early versus late catheter removal after rectal surgery were eligible. Primary outcomes were acute urinary retention and UTI; the secondary outcome was length of hospital stay. Early catheter removal was defined as removal up to 2 days after surgery, with late removal after postoperative day 2. The non-inferiority margin from an included trial was used for analysis of change in urinary retention (NI = 15 per cent). Pooled estimates of risk differences (RDs) were derived from random-effects models. Risk of bias was assessed using a modified Cochrane risk-of-bias tool. Results: Four trials were included, consisting of 409 patients. There was insufficient evidence to conclude non-inferiority of early versus late catheter removal for acute urinary retention (RD 9 (90 per cent c.i. −1 to 19) per cent; P NI = 0⋅31). Early catheter removal was superior for UTI (RD −11 (95 per cent c.i. −17 to −4) per cent; P = 0⋅001). Results for length of stay were mixed. There were insufficient data to conduct subgroup analyses. Conclusion: The existing literature is inconclusive for non-inferiority of early versus late urinary catheter removal for acute urinary retention. Early catheter removal is superior in terms of reducing the risk of UTI.

COVID-19 had a variable impact on urgent interventions among hospitalized patients in Ontario Canada.

The effects of global climate and environmental change endanger health, health systems, and public health infrastructure. As future public health and health services professionals, researchers, and clinicians, we will be tasked with protecting and promoting the health of communities in the face of these realities. However, there is limited integration of the environment-health nexus into the curricula of public health and health services research programs. Planetary health, an integrative paradigm linking the complex dynamics between the health of people to the natural systems on which we depend, offers an inroad to equipping emerging health system leaders with the skills and knowledge to protect people and the planet. We call on our institutions to follow other health disciplines, such as medicine, and embed planetary health and environmentally sustainable healthcare practices into core educational offerings.