Department of Anesthesia

University of Manitoba

In-Training Evaluation Report

PAIN FELLOWSHIP

Fellow: Staff Supervisor:

Dates: to

Evaluation code 1- unsatisfactory, rarely/never meets expectations

2- Below average, often falls short of expectations

3- Average, usually meets expectations

4- Above average, often above expectations

5- Outstanding, exceeds expectations

N/A could not assess

This evaluation form is designed to conform to the CanMeds 2000 model of educational goals, and lists the roles envisioned therein. The main attributes of each role are reflected in the specific items, staff are asked to rate the degree to which the trainee displays these attributes, and circle the corresponding value, Any 4 or 5 requires comment.

MEDICAL EXPERT
Knowledge – basic science / 1 / 2 / 3 / 4 / 5 / N/A
Knowledge – general clinical / 1 / 2 / 3 / 4 / 5 / N/A
Knowledge – Pain Physiology / 1 / 2 / 3 / 4 / 5 / N/A
Knowledge – Pain Medicine / 1 / 2 / 3 / 4 / 5 / N/A
Problem Solving / 1 / 2 / 3 / 4 / 5 / N/A
Technical skills / 1 / 2 / 3 / 4 / 5 / N/A
COMMUNICATOR
Rapport with / 1 / 2 / 3 / 4 / 5 / N/A
- patients / 1 / 2 / 3 / 4 / 5 / N/A
- families / 1 / 2 / 3 / 4 / 5 / N/A
- other staff / 1 / 2 / 3 / 4 / 5 / N/A
Delivery of Information to / 1 / 2 / 3 / 4 / 5 / N/A
- family / 1 / 2 / 3 / 4 / 5 / N/A
- staff / 1 / 2 / 3 / 4 / 5 / N/A
Accessing Information from / 1 / 2 / 3 / 4 / 5 / N/A
- family / 1 / 2 / 3 / 4 / 5 / N/A
- staff / 1 / 2 / 3 / 4 / 5 / N/A
HEALTH ADVOCATE
Identifies potential to improve / 1 / 2 / 3 / 4 / 5 / N/A
Identifies obstacles to change / 1 / 2 / 3 / 4 / 5 / N/A
Able to design changes / 1 / 2 / 3 / 4 / 5 / N/A
SCHOLAR
Familiar with current literature / 1 / 2 / 3 / 4 / 5 / N/A
Appraisal of literature / 1 / 2 / 3 / 4 / 5 / N/A
Teaching Skills / 1 / 2 / 3 / 4 / 5 / N/A
Applies knowledge in practice / 1 / 2 / 3 / 4 / 5 / N/A


In-Training Evaluation Report

PAIN FELLOWSHIP

PROFESSIONAL
Ethical behaviour / 1 / 2 / 3 / 4 / 5 / N/A
Responsible/conscientious / 1 / 2 / 3 / 4 / 5 / N/A
COLLABORATOR
Teamwork / 1 / 2 / 3 / 4 / 5 / N/A
Leadership / 1 / 2 / 3 / 4 / 5 / N/A
MANAGER
Awareness of cost/efficiency / 1 / 2 / 3 / 4 / 5 / N/A
Awareness of system / 1 / 2 / 3 / 4 / 5 / N/A
Accessing Information from / 1 / 2 / 3 / 4 / 5 / N/A
Organization / 1 / 2 / 3 / 4 / 5 / N/A

Comments:

I have read this ITER:

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Trainee’s Signature Date

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Fellowship Director’s Signature Date