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Background: Racialised trainees in Canada and the USA continue to disproportionately experience discrimination and harassment in learning environments despite equity, diversity, and inclusion (EDI) reform efforts. Using critical approaches to understand what problems have been conceptualised and operationalised as EDI issues within postgraduate medical education (PGME) is important to inform ongoing learning environment reform in resident training., Methods: We conducted a critical narrative review of EDI literature from 2009-2022 using critical race theory (CRT) and the concept of intersectionality to analyse how issues of discrimination in PGME have been studied. Our search yielded 2244 articles that were narrowed down to 349 articles for relevance to Canadian and American PGME contexts. We attended to reflexivity and our positionality in analysing the database and identifying themes related to EDI reform., Results: Interest convergence was noted in how EDI reform was rationalised primarily by increased productivity. Problems of learner representation, gender inequities and curricular problems were conceptualised as EDI issues. The role that racism played in EDI-related problems was largely invisible, as were explicit conceptualisations of race and gender as social constructs. Overall, there was a lack of critical or intersectional approaches in the literature reviewed. Misalignment was noted where studies would frame a problem through a critical lens, but then study the problem without attention to power., Discussion: Interest convergence and epistemic injustice can account for the absence of critical approaches due to the alignment of existing EDI work with institutional interests and priorities. Interest convergence conceptually limits existing EDI reform efforts in PGME. CRT and intersectionality connect racialised learner experiences to systemic phenomena like racism and other forms of discrimination to challenge dominant assumptions. Because they attend to power, critical approaches are key to understanding why inequities have persisted to advance equity in learning environments for racialised and intersectionally marginalised learners., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: The slow pace of change in respect of increasing the diversity of medical students suggests powerful actors are reproducing practices to support the status quo. Opening up medicine to embrace diversity thus requires the deconstruction of entrenched processes and practices. The first step in doing so is to understand how the actor-network of widening participation and access to medicine (WP/WA) is constructed. Thus, here we examine how the connections among actors in WP/WA in two different networks are assembled., Methods: A comparative case study using documents (n = 7) and interviews with staff and students (n = 45) from two medical schools, one United Kingdom and one Australian, was used. We used Callon's moments of translation (problematisation, interessement/operationalisation, enrolment, mobilisation) to map the network of actors as they are assembled in relation to one another. Our main actant was institutional WP to medicine policy (actor-as-policy)., Results: Our actor-as-policy introduced five other actors: the medical school, medical profession, high schools, applicants and medical school staff. In terms of problematisation, academic excellence holds firm as the obligatory passage point and focal challenge for all actors in both countries. The networks are operationalised via activities such as outreach and admissions policy (e.g., affirmative action is apparent in Australia but not the UK). High schools play (at best) a passive role, but directed by the policy, the medical schools and applicants work hard to achieve WP/WA to medicine. In both contexts, staff are key mobilisers of WP/WA, but with little guidance in how to enact policy. In Australia, policy drivers plus associated entry structures mean the medical profession exerts significant influence., Conclusions: Keeping academic excellence as the obligatory passage point to medical school shapes the whole network of WP/WA and perpetuates inequality. Only by addressing this can the network reconfigure., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

As the field of health professions education (HPE) continues to evolve, it is necessary to occasionally pause and reflect on the potential effects and outcomes of our research practices. While future-casting does not guarantee that impending negative consequences will be evaded, the exercise can help us avoid pitfalls. In this paper, we reflect on two terms that have taken hold as powerful idols in HPE research that stand above questioning and apart from critique: patient outcomes and productivity. We argue that these terms, and the ways of thinking they uphold, threaten the sustainability of HPE research-one at the level of the community and one at the level of the scholar. First, we suggest that HPE research's history of endorsing a linear and causal association ethos has driven its quest to connect education to patient outcomes. To ensure the sustainability of HPE scholarship, we must deconstruct and disempower patient outcomes as one of HPE's god-terms, as the pinnacle goal of educational activities. To be sustained, HPE research needs to value all of its contributions equally. A second god-term is productivity; it impairs the sustainability of the careers of individual researchers. Problems of honorary authorship, research output expectations, and comparisons with other fields have constructed a space where only scholars with sufficient privilege can prevail. If productivity persists as a god-term, the field of HPE research could decay into a space where new scholars are silenced-not because they fail to make important contributions, but because access is restricted by existing research metrics. These are two of many god-terms threatening the sustainability of HPE research. By highlighting patient outcomes and productivity and by acknowledging our own participation in propagating them, we hope to encourage others to recognize how our collective choices threaten the sustainability of our field., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Increasing the diversity of medical students, or widening participation (WP), is critical for social justice and healthcare delivery, and many governments are setting policies to encourage WP. However, establishing policy is only the first step in an educational change process: we also need to know "how" policy is enacted or how medical schools interpret and put into practice WP policy. Addressing this gap, the aim of this study was to examine policy enactment in six new UK medical schools with an explicit WP mandate., Methods: This qualitative study, underpinned by social constructivism, used semi-structured interviews to explore the experiences of key actors (6 Deans and 14 Admissions staff) of putting policy into practice when setting up a new medical school. Data coding and analysis were initially inductive, using thematic analysis. We then applied Ball's theory of policy enactment to organise the data into four contextual dimensions of 'situation', 'professional', 'material' and 'external'., Results: On the surface, there were many similarities across the six schools in terms of the four dimensions. However, how these dimensions interacted illuminated tensions and differences. For example, some schools found themselves increasingly subjected to local and extra-local rule systems, including pressure to follow host university norms and hosts struggling to accept that medical schools are heavily regulated. There were also tensions between the new medical schools and the medical education "establishment", including lack of power and being judged by overly narrow outcomes., Discussion: Different contexts seem to influence the enactment of WP to medicine in different places, even in the same country, even in medical schools established at the same time. That policy enactment is a complex, non-linear process of enactment is important to acknowledge: context is critical. Our findings will inform future policies and practices that aim to increase WP in medicine., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Cheating during medical training is a delicate subject matter with varying opinions on the prevalence, causes and gravity of cheating during training., Proposed Framework: In this article, the authors suggest that the decision to cheat is best viewed as the product of a person-by-situation interaction rather than indicating inherent dishonesty and/or extrinsic motivation in those who participate in cheating. This framework can explain why individuals who would typically default to honesty may participate in cheating if there is perceived justification for cheating and where situational variables, such as ease of cheating, rewards for cheating and perceived risk associated with cheating, make the decision to cheat appear rational., Discussion: They discuss why the impression that there is a culture of cheating can provide perceived justification for medical trainees to cheat if they have the opportunity. They then describe how aspects of medical training and assessment may enable or hinder cheating by trainees. Consistent with the person-by-situation interaction framework, they contend that our response to cheating should include interventions directed at both the person who cheated and situational variables that enabled cheating. Recognising that some forms of cheating may be widespread, difficult to detect and contentious (such as the creation and use of exam reconstructs), their proposal for dealing with suspected and pervasive cheating is to identify and target enabling variables such that the decision to cheat becomes less rational. Their hope is that in so doing, we can gradually nudge trainees and the culture of medical training towards honesty., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Health professions education curricula are undergoing reform towards social accountability (SA), defined as an academic institution's obligation to orient its education, service and research to respond to societal needs. However, little is known about how or which educational experiences transform learners and the processes behind such action. For example, those responsible for the development and implementation of undergraduate medical education (UGME) programs can benefit from a deeper understanding of educational approaches that foster the development of competencies related to SA. The purpose of this paper was to learn from the perspectives of the various partners involved in a program's delivery about what curricular aspects related to SA are expressed in a UGME program., Methods: We undertook a qualitative descriptive study at a francophone Canadian university. Through purposive convenience and snowball sampling, we conducted 16 focus groups (virtual) with the following partners: (a) third- and fourth-year medical students, (b) medical teachers, (c) program administrators (e.g., program leadership), (d) community members (e.g., community organisations) and (e) patient partners. We used inductive thematic analysis to interpret the data., Results: The participants' perspectives organised around four key themes including (a) the definition of a future socially accountable physician, (b) socially accountable educational activities and experiences, (c) characteristics of a socially accountable MD program and (d) suggestions for curriculum improvement and implementation., Conclusions: We extend scholarship about curricular activities related to SA from the perspectives of those involved in teaching and learning. We highlight the relevance of experiential learning, engagement with community members and patient partners and collaborative approaches to curriculum development. Our study provides a snapshot of what are the sequential pathways in fostering SA among medical students and therefore addresses a gap between knowledge and practice regarding what contributes to the implementation of educational approaches related to SA. We emphasise the need for educational innovation and research to develop and align assessment methods with teaching and learning related to SA., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Categorisation Can Bring Clarity: Categorisation is just what we do in health care. It allows for definitions to be shared, so conditions can be targeted and treatments standardised. It allows for concepts and constructs to become testable objects of research. And, with the increasing push for diversity and inclusion, it allows for disparities to be identified to evidence progress and enable accountability., Categorisation Can Also Confound: But could these distinctions be doing as much harm as good? In this article, I review work from the field of inclusive education, focusing particularly on "awarding gaps" and "differential attainment" (i.e. differences in the proportions of degrees with higher grades awarded to some groups of learners compared with others). In doing so, I draw attention to the paradox inherent in empirically studying these topics: increasing recognition of unfairness is dependent on categorising individuals into groups of students, which risks reinforcing negative, reductive associations and alienating those who cannot relate to their designation., Categorisation Requires Care: Using the case of ethnicity categorisation (and mixed ethnicity categories in particular), I use this paper to explore this unwelcome impact of categorisation in more detail. I acknowledge how difficult it would be to overhaul our system of categorisation and finish with thoughts on how we might mitigate its impact in our practice., (© 2024 The Author. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment., Methods: This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations., Results: Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment., Discussion: Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: The field of medical education is relatively new, and its boundaries are not firmly established. If we had a better understanding of the intricacies of the domain, we might be better equipped to navigate the ever-changing demands we must address. To that end, we explore medical education as a world wherein leaders harness agency, improvisation, discourse, positionality and power to act., Methods: Using the constructivist theory of figured worlds (FW), we conducted a narrative analysis of the stories medical education senior leaders tell about their roles and experiences in the world of medical education (n = 9)., Results: We identified four foundational premises about the world of medical education: (i) medical education stands at the intersection of three interrelated worlds of clinical medicine, hospital administration and university administration; (ii) medical education is shaped by and shapes the clinical learning environment at the local level; (iii) medical education experiences ubiquitous change which is a source of power; and (iv) medical education is energised by relationships between individuals., Discussion: Focusing on the FW theory's notions of agency, improvisation, discourse, positionality and power enabled us to describe the world of medical education as a complex domain existing in a space of conflicting power hierarchies, identities and discourses. Using FW allowed us to see the powerful affordances offered to medical education due to its position between worlds amid unceasing change., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Purpose: Prior to COVID, thousands of medical school and residency applicants traversed their countries for in-person interviews each year. However, data on the greenhouse gas emissions from in-person interviews is limited. This study estimated greenhouse gas emissions associated with in-person medical school and residency interviews and explored applicant interview structure preferences., Methods: From March to June 2022, we developed and distributed a nine-question, website-based survey to collect information on applicant virtual interview schedule, demographics and preference for future interview format. We calculated theoretical emissions for all interviews requiring air travel and performed a content analysis of interview preference explanations., Results: We received responses from 258 first-year and 253 fourth-year medical students at 26 allopathic US medical schools who interviewed virtually in 2020-2021 and 2021-2022, respectively. Residency applicants participating in the study were interviewed at a mean of 15.3 programs (SD 5.4) and had mean theoretical emissions of 4.31 tons CO 2 eq. Medical school applicants participating in the study were interviewed at a mean of 6.9 programs and had mean theoretical emissions of 2.19 tons CO 2 eq. Ninety percent of medical school applicants and 91% of residency applicants participating in the study expressed a preference for hybrid or virtual interviews going forward., Conclusion: In-person medical training interviews have significant greenhouse gas emissions. Virtual and hybrid alternatives have a high degree of acceptability among applicants., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Within medical school's holistic review of applicants includes a review of their distance travelled to get to this point in their education. The AAMC defines distance travelled (DT) as, 'any obstacles or hardships you've overcome to get to this point in your education or any life challenges you've faced and conquered'. What medical students consider as their distance travelled has not been explored. The authors sought to identify the factors medical students perceive are important for medical school admissions to consider when assessing someone's 'distance travelled' by asking current medical students to share their DT experiences along with the barriers and facilitators they encountered on their medical school journey., Methods: The authors conducted semi-structured interviews with US medical students through purposeful sampling methods. The social-ecological model framework was used to develop questions to elicit participants' experiences that contributed to their distance travelled. Interviews were conducted in 2021 and ranged from 60-75 minutes. Transcribed interviews were qualitatively analysed using interpretive description., Results: A total of 31 medical students from seven medical schools were included in the study. Overall, participants defined distance travelled as an applicant's hardships (e.g. being the primary caregiver for a family member) and privileges (e.g. having physician parents) they experienced. Three major themes were identified: (1) individual-level characteristics and factors, (2) interpersonal relationships and (3) aspects of the participants' community and society., Discussion: Our findings show that medical school applicants considered DT to be a valuable component of a holistic medical school admission process. Participants' experiences of DT were varied and complex. Our research suggests that admissions teams for medical schools should incorporate more comprehensive recruitment practices and inclusive methodological frameworks to accurately capture the diversity of identities and experiences of medical school applicants and to consider the factors that shape their journey to medical schools., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Electronic health records (EHRs) have transformed clinical practice. They are not simply replacements for paper records but integrated systems with the potential to improve patient safety and quality of care. Training physicians in the use of EHR is a highly complex intervention that occurs in a dynamic socio-technical health system. Training in this complex space is considered a wicked problem and would benefit from different analytic approaches to the traditional linear causal relationship analysis. Social Sciences theories see technological change in relation to complex social and institutional processes and provide a useful starting point., Aim: Our aim, therefore, is to introduce the medical education scholar to a selection of theoretical approaches from the Social Studies of Science and Technology (SSST) literatures, to inform educational efforts in training for EHR use., Methods: We suggest a body of theories and frameworks that can expand the epistemological repertoire of medical education scholarship to respond to this wicked problem. Drawing from our work on EHR implementation, we discuss current limitations in framing training for EHRs use as a research problem in medical education. We then present a selection of alternative theories., Results: Unified Theory of Acceptance and Use of Technology (UTAUT) explains the individual adoption of new technologies in the workplace and has four key constructs: performance/effort expectancy, social influence and facilitating conditions. Social Practice Theory (SPT), rather than focusing on individuals or institutions, starts with the activity or practice. The socio-technical model (STM) is a comprehensive theory that offers a multidimensional framework for studying the innovation and application of EHRs. Practical examples are provided., Conclusions: We argue that education for effective utilisation of EHRs requires moving beyond the epistemological monism often present in the field. New theoretical lenses can illuminate the complexity of research to identify the best practices for educating and training physicians., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

The Problem: Medical schools require highly skilled and committed clinical faculty to teach, assess, supervise and mentor students' clinical care. Medical education is facing a crisis in recruiting and sustaining these clinical teachers. Faced with multiple demands and responsibilities in fast-paced clinical environments, teachers may not have the time, resources or stamina to sustain these critical roles. Medical school leaders must commit to and provide structures and processes to attract, sustain and retain clinical teachers., Conceptual Framework: The authors use the lens of self-determination theory to frame approaches to support teacher sustainability. Self-determination theory describes sources of human motivation. The theory and its evidence base characterise three human psychological needs: autonomy, competence, and relatedness. This theory can bridge individual psychological and institutional leadership perspectives to help medical school leaders anticipate and respond to their clinical teachers' needs. The authors propose three practical steps: practices to advance employee-centredness, processes to align individual and institutional values, and restructuring education to support clinical teachers' needs alongside student and patient needs. The authors describe limitations to this relational approach that focuses on leadership actions and consider individual agency as another key factor for sustainability., Discussion: Medical school leaders can develop and apply theory-driven approaches to advance sustainability. Sustainability now and in the future requires careful attention to the needs of clinical teachers and to their relationships with and within medical schools., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Artificial intelligence (AI) is becoming increasingly used in medical education, but our understanding of the validity of AI-based assessments (AIBA) as compared with traditional clinical expert-based assessments (EBA) is limited. In this study, the authors aimed to compare and contrast the validity evidence for the assessment of a complex clinical skill based on scores generated from an AI and trained clinical experts, respectively., Methods: The study was conducted between September 2020 to October 2022. The authors used Kane's validity framework to prioritise and organise their evidence according to the four inferences: scoring, generalisation, extrapolation and implications. The context of the study was chorionic villus sampling performed within the simulated setting. AIBA and EBA were used to evaluate performances of experts, intermediates and novice based on video recordings. The clinical experts used a scoring instrument developed in a previous international consensus study. The AI used convolutional neural networks for capturing features on video recordings, motion tracking and eye movements to arrive at a final composite score., Results: A total of 45 individuals participated in the study (22 novices, 12 intermediates and 11 experts). The authors demonstrated validity evidence for scoring, generalisation, extrapolation and implications for both EBA and AIBA. The plausibility of assumptions related to scoring, evidence of reproducibility and relation to different training levels was examined. Issues relating to construct underrepresentation, lack of explainability, and threats to robustness were identified as potential weak links in the AIBA validity argument compared with the EBA validity argument., Conclusion: There were weak links in the use of AIBA compared with EBA, mainly in their representation of the underlying construct but also regarding their explainability and ability to transfer to other datasets. However, combining AI and clinical expert-based assessments may offer complementary benefits, which is a promising subject for future research., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: International medical graduates (IMGs) are forming an ever-increasing proportion of the medical workforce. Much of the discourse around IMGs is about their performance at work and interventions to improve it. This discourse, however, is rarely situated in the wider context of the experiences of IMGs as migrants despite the wider context of migration and acculturation being likely to have a significant impact on IMGs' well-being and, ultimately, performance at work., Objectives: The objectives of this article were to (1) raise awareness of the inextricable broader context within which IMGs are situated as migrants; (2) outline the impact this context might have on IMGs' performance; (3) discuss literature from the social sciences related to acculturation that could better inform the way we view IMG transition and performance; (4) highlight how acculturation theory can help inform the design, implementation and evaluation of interventions to facilitate the transition of IMGs into the host country and the workplace; (5) list some interventions that can provide support; and (6) suggest theory driven lines of enquiry to study acculturation in IMGs and the impact related issues might have on performance., Methods: This is a cross-cutting edge review drawing on selected theory and literature from the social sciences to explore its relevance to IMGs., Conclusion: The broader context of migration and acculturation should not be ignored when discussing IMG performance in the workplace or when instigating interventions to improve it. There is an urgent need to further evaluate the impact this broader context has on IMGs' well-being and performance., (© 2023 The Author. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Technology is being introduced, used and studied in almost all areas of health professions education (HPE), often with a claim of making HPE better in one way or another. However, it remains unclear if technology has driven real change in HPE. In this article, we seek to develop an understanding of the transformative capacity of learning technology in HPE., Methods and Outcomes: We first consider the wider scholarship highlighting the intersection between technology and pedagogy, articulating what is meant by transformation and the role of learning technology in driving educational transformation. We then undertake a synthesis of the current high visibility HPE-focused research. We sampled the literature in two ways-for the five highest impact factor health professional education journals over the past decade and for all PubMed indexed journals for the last 3 years-and categorised the extant research against the Substitution, Augmentation, Modification, Redefinition model. We found that the majority of research we sampled focussed on substituting or augmenting learning through technology, with relatively few studies using technology to modify or redefine what HPE is through the use of technology. Of more concern was the lack of theoretical justification for pedagogical improvement, including transformation, underpinning the majority of studies., Conclusions: While all kinds of technology use in learning have their place, the next step for HPE is the robust use of technology aiming to lead transformation. This should be guided by transformational educational theory and aligned with pedagogical context. We challenge HPE practitioners and scholars to work thoughtfully and with intent to enable transformation in education for future health professionals., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Much published research writing is dull and dry at best, impenetrable and off-putting at worst. This state of affairs both frustrates readers and impedes research uptake. Scientific conventions of objectivity and neutrality contribute to the problem, implying that 'good' research writing should have no discernible authorial 'voice'. Yet some research writers have a distinctive voice in their work that may contribute to their scholarly influence. In this study, we explore this notion of voice, examining what strong research writers aim for with their voice and what strategies they use., Methods: Using a combination of purposive, snowball and theoretical sampling, we recruited 21 scholars working in health professions education or adjacent health research fields, representing varied career stages, research paradigms and geographical locations. We interviewed participants about their approaches to writing and asked each to provide one to three illustrative publications. Iterative data collection and analysis followed constructivist grounded theory principles. We analysed interview transcripts thematically and examined publications for evidence of the writers' described approaches., Results: Participants shared goals of a voice that was clear and logical, and that engaged readers and held their attention. They accomplished these goals using approaches both conventional and unconventional. Conventional approaches included attention to coherence through signposting, symmetry and metacommentary. Unconventional approaches included using language that was evocative (metaphor, imagery), provocative (pointed critique), plainspoken ('non-academic' phrasing), playful (including humour) and lyrical (attending to cadence and sound). Unconventional elements were more prominent in non-standard genres (e.g. commentaries), but also appeared in empiric papers., Discussion: What readers interpret as 'voice' reflects strategic use of a repertoire of writing techniques. Conventional techniques, used expertly, can make for compelling reading, but strong writers also draw on unconventional strategies. A broadened writing repertoire might assist health professions education research writers in effectively communicating their work., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Understanding the factors that contribute to diagnostic errors is critical if we are to correct or prevent them. Some scholars influenced by the default interventionist dual-process theory of cognition (dual-process theory) emphasise a narrow focus on individual clinician's faulty reasoning as a significant contributor. In this paper, we examine the validity of claims that dual process theory is a key to error reduction., Methods: We examined the relationship between a clinical experience (staff and resident physicians) and viewing time on accuracy for categorising chest X-rays (CXRs) and electrocardiograms (ECGs). In two studies, participants categorised images as normal or abnormal, presented at viewing times of 175, 250, 500 and 1000 ms, to encourage System 1 processing. Study 2 extended viewing times to 1, 5, 10 and 20 s to allow time for System 2 processing and a diagnosis. Descriptives and repeated measures analysis of variance were used to analyse the proportion of true and false positive rates (TP and FP) as well as correct diagnoses., Results: In Study 1, physicians were able to detect abnormal CXRs (0.78) and ECGs (0.67) with relatively high accuracy. The effect of experience was found for ECGs only, as staff physicians (0.71, 95% CI = 0.66-0.75) had higher ECG TP than resident physicians (0.63, 95% CI = 0.58-0.68) in Study 1, and staff had lower ECG FP (0.10, 95% CI = 0.03-0.18) than resident physicians (0.27, 95% CI = 0.20-0.33) in Study 2. In other comparisons, experience was equivocal for ECG FPs and CXR TPs and FPs. In Study 2, overall diagnostic accuracy was similar for both ECGs and CXRs, (0.74). There were small interactions between experience and time for TP in ECGs and FP in CXRs, which are discussed further in the discussion and offer insights into the relationship between processing and experience., Conclusion: Overall, our findings raise concerns about the practical application of models that link processing type to diagnostic error, or to specific diagnostic error reduction strategies., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Medical education (ME) must rethink the dominant culture's fundamental assumptions and unintended consequences on less advantaged groups and society at large. Doing so, however, requires a robust understanding of what we are teaching, regardless of our intentions, and what is being learned across the multiple settings that our learners find themselves in, from classrooms to clinical spaces and beyond., Approach: Gaining such understandings and fully exploring the extent to which we are rising to the challenges of today's society in authentic ways require robust methodologies. In this research approaches paper, we introduce unfamiliar readers to one such methodology-critical ethnography. By doing so, we hope to demonstrate its potential for helping ME both identify and gain novel insight into necessary solutions for many of today's educational challenges regarding healthcare disparities and inequities., Conclusion: The readers of this paper will gain novel insights into how critical ethnographers see the world and ask questions, thereby changing the way they (the reader) see the world. At its heart, critical ethnography is about thinking differently and that is something that should be accessible to all. Doing so may also enhance our ability to both question dominant ways of thinking and, ultimately, to enact positive change in training and practices to enhance inclusivity and fairness for all regardless of their gender, race and status., (© 2024 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Gender bias is an enduring issue in the medical profession despite women being more represented within medical schools and the health care workforce in numerous countries across the world. There have been frequent calls for further exploration of gender-based discriminations within medical education, owing to its lasting impact on student's professional development and career trajectories. This paper presents an ethnographic exploration of the experiences of female medical students and doctors in the clinical learning environment (CLE), aiming to disrupt the cycle of gender inequity in the clinical workplace., Methods: Our research field involved two teaching wards in a Scottish urban hospital, where 120 h of non-participant observations were conducted over 10 months. Combining purposive and convenience sampling, we conducted 36 individual interviews with key informants, which included medical students, foundation doctors, postgraduate trainees, consultant supervisors, and other health care professionals such as nurses and pharmacists. Data was thematically analysed using Bourdieu's theory of social power reproduction. The research team brought diverse professional backgrounds and perspectives to the exploration of data on gendered encounters., Results: Combining the observational and interview data, five themes were generated, which suggested gender-related differentials in social and cultural capital that the participants acquired in the CLE. Experiences of discriminatory behaviour and stereotypical thought processes impacted the female students' engagement and drive towards learning, implying an adverse influence on habitus. In contrast, the valuable influence of gendered role-models in building confidence and self-efficacy signified a positive transformation of habitus. The research participants displayed considerable internalisation of the gendered processes in the CLE that appeared to be linked to the transient nature of clinical placements., Conclusions: This research reveals that despite constituting the majority demographic of medical school, female students struggle to gain social and cultural capital. Gendered hierarchies that structure clinical workplaces disadvantage female students and doctors, and the differential experiences transform their habitus. Based on our theoretically informed investigation, we advocate for role-models given their positive impact on students' and doctors' habitus. Additionally, medical educators may consider extended clinical placements that provide opportunities for female students and early-career doctors to secure social and cultural capital through integrating better in health care teams and building meaningful interprofessional relationships., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Students within a cohort might employ unique subsets of learning strategies (LS) to study. However, little research has aimed to elucidate subgroup-specific LS usage among medical students. Recent methodological developments, particularly person-centred approaches such as latent profile analysis (LPA), offer ways to identify relevant subgroups with dissimilar patterns of LS use. In this paper, we apply LPA to explore subgroups of medical students during preclinical training in anatomy and examine how these patterns are linked with learning outcomes., Methods: We analysed the LS used by 689 undergraduate, 1st and 2nd-year medical students across 6 German universities who completed the short version of the Learning Strategies of University Students (LIST-K) questionnaire, and answered questions towards external criteria such as learning resources and performance. We used the thirteen different LS facets of the LIST-K (four cognitive, three metacognitive, three management of internal and three management of external resources) as LPA indicators., Results: Based on LPA, students can be grouped into four distinct learning profiles: Active learners (45% of the cohort), collaborative learners (17%), structured learners (29%) and passive learners (9%). Students in each of those latent profiles combine the 13 LS facets in a unique way to study anatomy. The profiles differ in both, the overall level of LS usage, and unique combinations of LS used for learning. Importantly, we find that the facets of LS show heterogeneous and subgroup-specific correlations with relevant outcome criteria, which partly overlap but mostly diverge from effects observed on the population level., Conclusions: The effects observed by LPA expand results from variable-centered efforts and challenge the notion that LS operate on a linear continuum. These results highlight the heterogeneity between subgroups of learners and help generate a more nuanced interpretation of learning behaviour. Lastly, our analysis offers practical implications for educators seeking to tailor learning experiences to meet individual student needs., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Qualitative approaches have flourished in medical education research. Many research articles use the term 'lived experience' to describe the purpose of their study, yet we have noticed contradictory uses and misrepresentations of this term. In this conceptual paper, we consider three sources of these contradictions and misrepresentations: (1) the conflation of perspectives with experiences; (2) the conflation of experience with lived experience; and (3) the conflation of researching lived experience with phenomenology. We offer suggestions to facilitate more precise use of terminology., Argument: Our starting point is to free researchers from unnecessary shackles: Not every problem in medical education should be studied through experience, nor should every study of experience be phenomenological. Data based on participants' perceptions, beliefs, opinions and thoughts, while based on reflections of experiences, are not in and of themselves accounts of experience. Lived experiences are situated, primal and pre-reflective; perspectives are more abstract. Lived experience-as opposed to experiences as such-deeply attune to bodies, relationality, space and time. There is also a difference between experiences as lived, how a person makes sense of these and what the researcher interprets and represents. Phenomenology is a meaningful approach to the study of lived experience, but other approaches, such as narrative inquiry and self-study, can also offer useful avenues for undertaking this type of research., Discussion: We aim to broaden researchers' scope with this paper and equip researchers with the information they need to be clear about the meaning and use of the terms experience and lived experience. We also hope to open new methodological possibilities for researching experiences as lived and, through highlighting tensions, to prompt researchers of lived experience to strive for ontological closeness and resonance., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Globally, medical schools are operationalising policies and programming to address Indigenous health inequities. Although progress has been made, challenges persist. In Canada, where this research is conducted, Indigenous representation within medical schools remains low, leaving a small number of Indigenous advocates leading unprecedented levels of equity-related work, often with insufficient resources. The change needed within medical education cannot fall solely on the shoulders of Indigenous Peoples; non-Indigenous Peoples must also be involved. This work aims to better understand the pathways of those engaged in this work, with careful consideration given to the facilitators and barriers to ongoing engagement., Methods: Data collection and analysis were informed by narrative inquiry, a methodology that relies on storytelling to uncover nuance and prompt reflection. In this paper, we focus on interview data collected from Canadian non-Indigenous medical educators and leaders (n = 10). Participants represented different career stages, (early to late career) and occupied a mix of clinical, administrative and education roles., Results: Although each participant's entry into reconciliatory work was unique, we identified common drivers actuating their engagement. Oftentimes their participation was tied to administrative work or propelled by experiences within their roles that forced them to confront the systemic inequalities borne by Indigenous Peoples in both academic and healthcare settings. Some admitted to struggling with understanding their appropriate role in Indigenous reconciliation; their participation often proceeded without firm support., Conclusion: Medical schools have an obligation to ensure their faculty, including non-Indigenous Peoples, are equipped to fulfil social accountability mandates regarding Indigenous health. Our findings generate a better understanding of the tensions inherent in this equity work. We urge others to reflect on their role in Indigenous reconciliation, or else medical schools risk generating a false sense of individual and institutional progress., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Despite the constant presence of change and innovation in health professions education (HPE), there has been relatively little theoretical modelling of such change, the experiences of change, the ideology associated with change or the unexpected consequences of change. In this paper, the authors explore theoretical approaches to the adoption of innovations in HPE as a way of mapping a broader theoretical landscape of change., Method: The authors, HPE researchers with an interest in technology adoption and systemic change, present a narrative review of the literature based on a series of thought experiments regarding how communities and individuals respond to the introduction of new ideas or methods. This research investigates the stages of innovation adoption, from the emergence and hype around new ideas to the concrete experiences of early adopters., Results: When an innovation first emerges, there is often little concrete information available to inform potential adopters, leaving it susceptible to hype, both positive and negative. This can be described using the Gartner Hype Cycle model, albeit with important caveats. Once the adoption of an innovation gets underway, early adopter user experiences can inform those that follow. This can be described using Rogers' diffusion of innovation model, again with caveats. Notably, neither model goes beyond the point of single point-in-time, yes/no, individual adoption. Other approaches, such as learning curve theory, are needed to track uptake and maintenance by individuals over time., Significance: This expanded theoretical base, while still somewhat instrumentalist, combined with complementary theoretical perspectives can afford opportunities to better explore reasons for variance, volunteerism and resistance to change. In summary, change is complicated and nuanced, and better models and theories are needed to understand and work meaningfully with change in HPE. To that end, the authors seek to encourage richer and more thoughtful research and scholarly thinking about change and a more nuanced approach to the pursuit of change in HPE as a whole., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Health and self-determination are recognised as universal human rights. Health professional education research and practice hold the capacity to prioritise values, worldviews and agendas that envisage sustainable and equitable futures for the entire community served. This paper explores the need for the co-location of Indigenous research paradigms in health professional education research and teaching. Indigenous communities have a long history of science, research and sustainable living and are holders of ways of knowing, being and doing that can shape actions and priorities in health research that value equity and sustainability., Discussion: Knowledge construction in health professional education research does not occur in isolation nor is it value neutral. A continued dominance of the biomedical approach to health creates a system of innovation that is unbalanced and unable to deliver health outcomes demanded by contemporary society. As power and hierarchies are embedded in health professional education research and praxis, transformative action is required to bring forth marginalised voices in research processes. Critical reflexivity regarding the ontological, epistemological, axiological and methodological positioning of researchers is an important step towards creating and sustaining research structures that effectively value and co-locate different perspectives in knowledge production and translation., Conclusion: Working towards more equitable and sustainable futures for Indigenous and non-Indigenous communities requires health care systems to be informed and guided by different knowledge paradigms. This can work to avoid the ongoing reproduction of inefficient biomedical structures and purposefully disrupt the status quo of health inequities. Realising this requires the effective co-location of Indigenous research paradigms and ways of working into health professional education research that centre relationality, wholism, interconnectedness and self-determination. This calls for a raising of the critical consciousness of health professional education research academies., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)