QUEST at 25: An enduring innovation in Canadian urology

The Royal College certification exam in urology is a high-stakes assessment that provokes anxiety in trainees and program directors alike. At the core of this anxiety is a training model where residents face an overwhelming and proliferating amount of knowledge without certainty about the contours of competency to pass the certifying exam. In 1997, Dr. Andrew MacNeily, then at Queen’s University, followed through on an idea of bringing together Canadian graduating residents for a simulated exam in order to provide feedback on their preparedness vis-a-vis their peers. Hence, the Queen’s Urology Examination and Skills Training, colloquially known as QUEST, was born. For the last 25 years, it has become a key pitstop along the journey of minting the next generation of Canadian urologists. QUEST has also served as a model for subsequent Canadian educational initiatives.

The course has been hosted by the faculty at Queen’s University, with a brief interregnum at the University of Western Ontario in 2002. It has withered the COVID-19 pandemic by offering a virtual program for the 2021 and 2022 graduating classes. The virtual program was instituted before the Royal College adopted this mode of exam delivery.

QUEST is composed of an exam component and a didactic course. Over the years, the course had been organized by Queen’s and Western faculty, and now under the direction of faculty from the University of Ottawa, offers a collection of orphan topics left unaddressed by other educational events. The exam has also adapted to the evolving format of the Royal College exam. It is composed of a written and an Objective Structured Clinical Examination (OSCE) component. The written exam initially consisted of short-answer questions (SAQs). However, when the Royal College removed SAQs from its written exam, leaving only multiple-choice questions (MCQs), an MCQ component was added to the QUEST exam. The OSCE component, usually the most anxiety-provoking aspect, is an assessment tool that is usually less familiar to these written exam veterans of multiple university degrees. The success of the OSCE is contingent on the generous participation of multiple examiners over the years from academic and community practices.

L’un des objectifs clés de cet événement pédagogique est de reproduire l’expérience de l’examen du Collège royal chez les candidats. C’est pour cette raison qu’il a été reconnu assez t ô t que l’examen devait être offert dans les deux langues. Ainsi, nos participants francophones ont eu la chance de pratiquer dans leur langue maternelle. L’amélioration de la qualité du fran ç ais est un objectif important avec l’engagement de traducteurs professionnels et d’examinateurs francophones.

Funded initially by partnerships with local pharma, the Canadian Urological Association recognized the value of this educational event in 2017 and began supporting the event through annual unrestricted educational grants. Based on survey feedback from candidate and active members of the association, QUEST continues to be viewed as a highly valued initiative and worthy of ongoing support.

Since its inception, 714 residents have participated in QUEST — the majority of the CUA membership. When held in person, the exam is a main social gathering for the graduating residents that promotes camaraderie at a particularly stressful period of training. These deepened relationships hopefully foster friendships and collaboration that last throughout a career in Canadian urology.

Beyond its educational value, QUEST has served as an important driver of Canadian scholarly work. Over the years, at least 15 peer-reviewed papers, and many more abstracts have been published as a result of this event. When the CanMEDS framework was introduced, many programs struggled to incorporate it into the teaching curriculum and generate appropriate assessment tools. QUEST has served as an incubator to evaluate graduating residents’ grasp of different roles, such as scholar, communicator, manager, and health advocate.^1,2

QUEST has also allowed the evaluation of the study habits of urology residents and helped identify important learning needs. With an ongoing opioid epidemic, surveys have looked at the narcotics prescribing habits of graduating residents.³ When new technology was introduced into practice, such as prostate magnetic resonance imaging, QUEST assessed the experience of trainees into its interpretation. It has also gauged graduates’ comfort with performing major oncological procedures independently and their level of exposure to robotic surgery when this surgical approach proliferated in Canadian academic institutions. At a time when person-power in Canadian urology is a salient topic, this venue has served as an important source of information on the graduates’ attitudes on fellowships and jobs.⁴ QUEST has also allowed the assessment of burnout among graduating Canadian urology residents and the impact of the pandemic on the well-being of our trainees.

Most importantly, performance on QUEST has been shown to be a predictor of outcomes on the Royal College exam, as well as the American board of Urology – Part 1.⁵ We have also shown that training programs play a key role in their residents’ performance on these summative exams.⁶

As we celebrate the 25^th anniversary of QUEST, it is fitting to acknowledge the contributions of this important Canadian institution to urology education and scholarship. This innovative program, that started with an idea, has adapted to a changing educational landscape and is thriving 25 years later. The support of the CUA has placed it on solid financial footing and we hope that it keeps bringing value to the membership.