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Objectives: Professional identity formation (PIF) is a growing area of research in medical education. However, it is unclear whether the present research base is suitable for understanding PIF in physicians considered to be under-represented in medicine (URM). This meta-ethnography examined the qualitative PIF literature from 2012 to 2019 to assess its capacity to shine light on the experiences of minoritised physicians., Methods: Data were gathered using a search of six well-known medical education journals for the term 'professional identit*' in titles, keywords, abstracts and subheadings, delineated with the date range of 2012-2019. All non-relevant abstracts were removed and papers were then further reduced to those that focused only on learners' experiences. This left 67 articles in the final dataset, which were analysed using a collaborative approach among a team of researchers. The team members used their professional expertise as qualitative researchers and personal experiences as minoritised individuals to synthesise and interpret the PIF literature., Results: Four conceptual categories were identified as impacting PIF: Individual versus Sociocultural Influences; the Formal versus the Hidden Curriculum; Institutional versus Societal Values; and Negotiation of Identity versus Dissonance in Identity. However, a major gap was identified; only one study explored experiences of PIF in URM physicians and there was an almost complete absence of critical stances used to study PIF. Combined, these findings suggest that PIF research is building on existing theories without questioning their validity with reference to minoritised physicians., Conclusions: From a post-colonial perspective, the fact that race and ethnicity have been largely absent, invisible or considered irrelevant within PIF research is problematic. A new line of inquiry is needed, one that uses alternative frameworks, such as critical theory, to account for the ways in which power and domination influence PIF for URM physicians in order to foreground how larger sociohistorical issues influence and shape the identities of minoritised physicians., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: As a contribution to the State of the Science issue on 'The problem with solutions', this paper discusses how technology-mediated and assumedly simple and straightforward solutions to professional problems in fact require extensive work from professionals in order that generalised tools and procedures can be made sense of, adapted and employed in local practice., Theoretical Perspective: The authors introduce a perspective on epistemic practices in professional work and learning in order to conceptualise and discuss the diversity of the knowledge-related actions required to perform professional services. They discuss how the growing numbers and diversity of knowledge-generating actors who aspire to inform professional practice create 'multi-charged' work settings, imbued with multiple objectives and purposes. This development presents new epistemic challenges to professionals, which require extended capacities for knowledge work., Summary: The authors give examples from empirical studies conducted in Nordic health care settings, which relate to nurses' engagement with repositories of clinical procedures and to the development of new medical technologies for clinical use. They show how work performance in both cases depends on a range of epistemic practices (ie, collective ways of exploring, assessing, critically examining and justifying knowledge claims), which are necessary if the general tools and technologies are to be put to work in the local environment. This forms a core dynamic in practitioners' work-based learning as it moves between what is known and what remains to be explored or improved., Conclusions: The paper argues that the widespread belief in simple or versatile solutions is challenged by research that reveals the diversity of the knowledge practices needed to perform professional services. The paper suggests that professional communities might pay more attention to epistemic practices as means to handle complexity. It raises intriguing questions and discusses implications for medical education., (© 2020 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Learning technologies are ubiquitous in medical schools, implemented in anticipation of more effective, active and authentic learning and teaching. Such thinking appears to be an instance of solutionism. The evidence is that academics' adoption of learning technologies is often limited in scale and scope and frequently fails to transform their teaching practices., Purpose: This paper aims to provide a contextualised analysis of considerations pertinent to the adoption of learning technologies by teaching staff. We contextualise a framework for understanding adoption of learning technologies in higher education by medical education., Conclusions: We identify multiple precursors that predict individual patterns of adoption, illuminating factors related to the technology, the individual staff member charged with adoption and the working environment. We offer conceptual clarity to the vexed issue of learning technology adoption and provide evidence explaining why, despite their widely promulgated potential, learning technologies do not offer an easy route to the transformation of medical education., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: A wellness crisis exists among physicians and medical trainees. High rates of burnout, depression, stress and other states of impaired wellness have driven a sense of urgency to create solutions, and the medical education community has mobilised impressively. However, we argue-and data suggest-that this rush to find solutions has outpaced our efforts to more fully understand the nature of impaired wellness in medicine. This, we believe, has led to the implementation of solutions informed by limited understanding of the problems we intend to solve., Methods: In this paper, we explore three contributors to this situation: (i) shaky definitions and conceptualisations of wellness, (ii) the predominance of deductive, quantitative research informing our understanding and current solutions, and (iii) the reliance on a 'disease-focused' approach to addressing impaired wellness in physicians and trainees. We discuss how these contributors have led to the current state of the science of wellness in medicine: one characterised by an expanding array of solutions built upon narrow conceptualisations of wellness and how it can be impaired., Discussion: Moving beyond the current state of the science on wellness in medicine will require three critical developments: (i) consistent use of clear definitions of wellness; (ii) expanding our methodologies to include those utilising direct interaction with participants; and (iii) moving beyond solutions informed by a disease-model approach. We propose a different way of thinking about wellness: one based on what we view as an inherent-and potentially unavoidable-risk of experiencing impairment during a career in medicine. We argue that efforts to extinguish and eliminate all states of impaired wellness may also eliminate opportunities to develop constructive coping mechanisms and future resilience, and that wellness may best be conceptualised as healthy and authentic engagement with the inevitable adversity of a career in medicine., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Objectives: A challenge to competency-based medical education is the verification of skill acquisition. Digital badges represent an innovative instruction strategy involving the credentialing of competencies to provide evidence for achievement. Despite increasing interest in digital badges, there has been no synthesis of the health care education literature regarding this credentialing strategy. The present authors proposed to address this gap by conducting the first systematic review of digital badges in health care education, to reveal pedagogical and research limitations, and to provide an evidence-based foundation for the design and implementation of digital badges., Methods: A systematic search of the medical education literature from January 2008 to March 2019 was conducted using MEDLINE, Web of Science, CAB Abstracts and ScienceDirect. Included studies described digital badges in academic or professional medical education programmes in any health care profession. Included studies were appraised and quality assessment, methodological scoring, quantitative analysis and thematic extraction were conducted., Results: A total of 1050 relevant records were screened for inclusion; 201 full text articles were then assessed for eligibility, which resulted in the identification of 30 independent papers for analysis. All records had been published since 2013; 77% were journal articles, and 83% involved academic health care education programmes. Scores for quality were relatively moderate. Thematic analyses revealed implications for the design and implementation of digital badges: learner characteristics may moderate student outcomes; the novelty effect can negate the value of digital badges, and educators may overcome instruction-related challenges with digital badges using design and implementation strategies such as the creation of badging ecosystems., Conclusions: The results indicate a growing momentum for the use of digital badges as an innovative instruction and credentialing strategy within higher education and provide evidence for outcomes within a learner-centred, competency-based model of medical education. There is a paucity of research to support the design and implementation of this credentialing system in health care education. The potential benefits necessitate future high-quality analyses reporting institutional, patient and workplace-based outcomes to evaluate the effectiveness and moderating conditions of digital badges., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Sociocultural learning theories play an important part in medical education. When Etienne Wenger-Trayner described 'communities of practice' oriented around three common features (mutual engagement, joint enterprise, shared repertoire), his approach was enthusiastically embraced across a range of fields, including those of clinical medicine and medical education. However, this model is limited by its focus on a single community. Recently, leading sociocultural learning theorists including Wenger-Trayner have proposed the landscape of practice as a model for how learner identities develop, but this theory has not yet been utilised in medical education. In this Cross-cutting Edge paper, I describe the key features of landscapes of practice. The landscape of practice encompasses all the communities of practice, and learners can move between these. The boundaries between communities of practice are particularly fertile settings for learning, either through occasional forays across borders or through complete multimembership of two or more communities of practice. The capacity to navigate knowledge acquisition and identity formation across the landscape, known as 'knowledgeability,' therefore becomes crucial. This paper concludes by describing possible applications of the landscapes of practice model in medical education practice and research. The model provides a rich framework for approaching cross-discipline learning, although it has been criticised for failing to address the difficulties created by wide disparities in power within communities and for an unrealistically collaborative (rather than competitive) view of boundary relations. Nevertheless, it provides a novel way of understanding the identity formation of medical trainees and students., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: The notion of culture is increasingly invoked in the medical education literature as a key influence on how educational strategies unfold, and culture change is frequently identified as a necessary precursor to progress. A meaningful perspective on what culture means is often missing from these discussions, however. Without a theoretically grounded notion of culture, calls for culture change are challenging to interpret and to act upon., Objective: In this cross-cutting edge paper, we explore how culture has been defined and theorised using three lenses: the organisational perspective; the identity perspective, and the practice perspective. We consider what each perspective might offer to medical education researchers., Results: Each of these perspectives draws on a range of disciplinary influences, and none represents a singular theory of culture. Broadly, the organisational perspective directs our attention to the shared assumptions and values that bind individuals within an organisation. It tends to view culture through a strategic lens; culture may be either a barrier to or a facilitator of the changes that are inevitably required of an organisation if it is to maintain its relevance. The identity perspective, particularly the notion of figured worlds, alerts us to the power of communal narratives to shape how individuals see themselves within particular cultural worlds. The practice perspective emphasises what actually occurs in practice, avoiding symbolic ideas about culture and shared values and instead privileging activity and human-material networks or arrangements., Conclusions: These diverse perspectives share a common thread- they shift our research gaze beyond the individual, allowing us instead to see how those individuals form organisations, inhabit cultural worlds and constitute practices. They afford substance and direction for explorations of culture, and thus offer the promise of a more nuanced understanding of some of medical education's most challenging problems., (© 2019 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Impostor syndrome (IS) is increasingly recognised as a condition among physicians and physicians in training. Impostor syndrome is especially problematic because of its association with increased rates of burnout and suicide. In order to address this issue, we need to fully understand its prevalence, scope, and factors associated with IS. The purpose of this scoping review is to analyse the existing literature on IS among practising physicians and physicians in training in order to identify current trends and directions for future research., Methods: The authors conducted a literature search of nine databases for any articles on IS among practising physicians or physicians in training published prior to January 2019. Two reviewers independently screened articles and identified 18 papers meeting the study inclusion criteria. Two authors independently extracted data and performed quantitative and qualitative syntheses consistent with best practice recommendations for scoping reviews., Results: Most studies utilised the Clance Impostor Phenomenon Scale and cited rates of IS ranging from 22% to 60%. Studies found that gender, low self-esteem and institutional culture were associated with higher rates of IS, whereas social support, validation of success, positive affirmation, and both personal and shared reflections were protective. Overall, IS was also associated with higher rates of burnout., Conclusions: This review summarises the existing literature on IS among practising physicians and physicians in training, providing valuable insights and areas for future research., (© 2019 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

In this paper, I argue that the role of values in theory selection is an important issue within medical education. I review the underdetermination argument, which is the idea within philosophy of science that the data serving as evidence for theories are by themselves not sufficient to support a theory to the exclusion of alternatives. There are always various explanations compatible with the data, and we ultimately appeal to certain values as our grounds for choosing one theory over another. I explore some of the ways contemporary feminist philosophers have chosen to grapple with the problem of underdetermination and proposed solutions to systematize how values might be incorporated into theory choice, drawing primarily from the work of Helen Longino and Elizabeth Anderson. I conclude by discussing how value-laden inquiry should be incorporated within medical education to promote reflection towards medicine's normative underpinnings., (© 2019 John Wiley & Sons Ltd.)

Context: Within the social sciences, researchers increasingly build on visual methods to explore complex phenomena and understand how people experience and give meaning to this complexity. Amongst the variety of visual methods available, rich pictures are beginning to gain traction in health professions education (HPE) research., Approach: A rich picture is a pictorial representation of a particular situation, including what happened, who was involved, how people felt, how people acted, how people behaved, and what external pressures they acted upon. Rich pictures expand our perspective; they may highlight connections, illuminate the big picture and reveal unexpected emotions. Although new methods bring excitement to the field, it is our responsibility to also be cautious and insightful about their limitations. Rich pictures are a method in evolution in HPE research, with many unknowns about what is possible and what is optimal., Purpose: In the current paper, we aim to map out the background, describe the process and share some reflective insights of using rich pictures as a data collection method., (© 2019 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: The prevalence of depressive symptoms among medical students has been found to be higher than among other students because of their longer studying time, higher workload and larger financial burden. Despite the availability of reviews examining this, some have focused solely on one country, whereas others used databases containing papers of solely one language; therefore, the results from reviews might not be comprehensive. Against this background, this overview aims to synthesise the results from all the published systematic reviews of depression among medical students, in order to provide a more accurate result., Methods: A systematic search was conducted of online databases for published systematic reviews or meta-analyses examining the prevalence of depressive symptoms among medical students. The findings of individual studies included in these reviews were extracted and then combined with a random-effects model. Subgroup analysis was conducted by regions., Results: A total of 10 studies were selected in this overview, involving 249 primary studies and 162 450 medical students. MEDLINE was the most popular database used in these studies. The overlapping of primary studies in these reviews was appreciably high, except for three studies that focused on specific countries. The overall pooled prevalence was 27.0% (95% CI, 24.7-29.5%). Significant subgroup differences were detected (p < 0.001). The pooled prevalence among studies in the Western Pacific Region was the lowest, 18.9% (95% CI, 11.7-29.0%), whereas that in Africa (40.9%) was the highest (95% CI, 28.8-54.4%). The top five significant factors associated with depressive symptoms were: (i) year of study; (ii) gender; (iii) personal issues; (iv) family relations or issues, and (v) health status., Conclusions: Depression affected around a quarter of medical students in general and 40.9% of students in Africa. It is suggested that medical schools and health authorities should introduce preventive measures to curb the high prevalence of depressive symptoms., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: 'Complexity' is fast becoming a 'god term' in medical education, but little is known about how scholars in the field apply complexity science to the exploration of education phenomena. Complexity science presents both opportunities and challenges to those wishing to adopt its approaches in their research, and debates about its application in the field have emerged. However, these debates have tended towards a reductive characterisation of complexity versus simplicity. We argue that a more productive discussion centres on the multiplicity of complexity orientations, with their diverse disciplinary roots, concepts and terminologies. We discuss this multiplicity and use it to explore how medical education researchers have taken up complexity science in prominent journals in the field., Methods: We synthesised the health sciences and medical education literature based on 46 papers published in the last 18 years (2000-2017) to describe the patterns of use of complexity science in medical education and to consider the consequences of those patterns for our ability to advance scholarly conversations about 'complex' phenomena in our field., Results: We identified four patterns in the use of complexity science in medical education research. Firstly, complexity science is described in a variety of ways. Secondly, multiple approaches to complexity are used in combination in single papers. Thirdly, the type of complexity science used tends to be left implicit. Fourthly, the complexity orientation used is much more commonly located using secondary source citation rather than primary source citation., Conclusions: The presence of these four patterns begs the question: Do medical education scholars understand that there are multiple legitimate orientations to complexity science, deriving from distinct disciplinary origins, drawing on different metaphors and serving distinct purposes? If we do not understand this, a cascade of potential consequences awaits. We may assume that complexity science is singular in that there is only one way to do it. This assumption may cause us to perceive our way as the 'right' way and to disregard other approaches as illegitimate. However, this perception of illegitimacy may limit our ability to enter into productive dialogue about our complexity science-inspired research., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Medical education has not been immune from forces for globalisation in the contemporary world. At the same time the social accountability of medical schools in addressing local health priorities has been emphasised. This paper explores the global-local tension in medical education through a careful selection of key overview papers., Globalisation: Globalisation in medical education has taken two main forms: economic and altruistic. The former includes licensing curricula, recruiting internationally and establishing 'offshore' schools or campuses. Altruistic collaborations focus on the spread of learning and educational innovations. Both forms bring benefits but have been subject to critique for their differential impact and focus on educational inputs rather than outputs., Social Accountability: Social accountability requires medical schools to direct their activities to local priorities and to serving local health systems. Adoption of the principles of social accountability compels all medical schools to ask questions of their educational programmes and graduate outcomes. However, these are globally interdependent questions and are the intent of some well-known social accountability collaborations. It is naïve to think that adoption of a social accountability agenda by all medical schools would necessarily reduce global health inequity. A recent Australian example shows that workforce maldistribution, for example, is resistant to even high-level intervention., Conclusions: It is yet too early to fully accept that 'think global, act local can be turned on its head'. There is much research to be carried out, particularly on the outcomes and impacts of medical education. Establishing cause and effect is a challenge, as is determining whether globalisation or localisation can contribute to greater global health equity. If we are ever to resolve the global-local tension in medical education, we need more evidence on the outcomes of what we do, whether globally or locally inspired., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: In recent years, point-of-care ultrasound (POCUS) has become a widely used clinical tool in a number of clinical specialties. In response, POCUS has been incorporated into medical curricula across the learning continuum, bolstered by enthusiastic appraisals of the technology's benefits for learners, clinicians and patients. In this project, we have sought to identify and understand the effects of dominant discourses influencing the integration of POCUS into medical education., Methods: We conducted a Foucauldian critical discourse analysis (CDA) to identify and analyse discourses that legitimise and privilege the use of POCUS in medical education. We assembled an archive of 473 texts published between 1980 and 2017. Each article in the archive was analysed to identify frequently occurring truth statements (expressing concepts whose truths are unquestioned within particular discourses) that we used to characterise the major discourses that construct representations of POCUS in medical education., Results: We identified three dominant discourses: (i) a visuo-centric discourse prioritising the visual information as truth over other clinical data; (ii) a utilitarian discourse emphasising improvements in patient care; and (iii) a modernist discourse highlighting the current and future needs of clinicians in our technological world. These discourses overlap and converge; the core discursive effect makes the further elevation of POCUS in medical education, and the resulting attenuation of other curricular priorities, appear inevitable., Conclusions: The three dominant discourses identified in this paper engender ideal conditions for the proliferation of POCUS in medical education through curricular guidelines, surveys of adherence to these guidelines and authoritative position statements. By identifying and analysing these dominant discourses, we can ask questions that do not take for granted the assumed truths underpinning the discourses, highlight potential pitfalls of proposed curricular changes and ensure these changes truly improve medical education., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Coaching has been employed successfully in the competitive sports, professional music, and business and corporate worlds. It is now emerging as a training modality in medical education., Objectives: This paper reviews the current evidence on coaching strategies for doctors and medical students., Methods: An applied literature search was conducted in PubMed, MEDLINE and Web of Science. Predetermined definitions of coaching interventions and their evaluations were used to narrow 993 papers down to 21, which were included in the final review. The 21 papers were critiqued with reference to validated scoring metrics., Results: There are many papers discussing the merits of coaching in the world of medicine, but few evaluations of coaching interventions. Existing coaching methodologies can be broadly summarised into three categories: coaching for doctor/student well-being and resilience; coaching for improved non-technical skills, and coaching for technical skills. Identification of suitable papers for inclusion is complicated by theoretical uncertainty regarding coaching: many papers use the term as a synonym for teaching or mentoring. The strongest evidence for coaching lies in the teaching of technical skills., Conclusions: There is weak- to medium-strength evidence to support coaching as a method of improving doctor well-being and enhancing non-technical skills, although the evidence base is limited as a whole. This review identifies strong evidence to support coaching as a method to improve technical skills. There is great scope for further studies investigating the power of coaching in medical students and doctors., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Simulation-based medical education (SBME) is now ubiquitous at all levels of medical training. Given the substantial resources needed for SBME, economic evaluation of simulation-based programmes or curricula is required to demonstrate whether improvement in trainee performance (knowledge, skills and attitudes) and health outcomes justifies the cost of investment. Current literature evaluating SBME fails to provide consistent and interpretable information on the relative costs and benefits of alternatives., Content: Economic evaluation is widely applied in health care, but is relatively scarce in medical education. Therefore, in this paper, using a focus on SBME, we define economic evaluation, describe the key components, and discuss the challenges associated with conducting an economic evaluation of medical education interventions. As a way forward to the rigorous and state of the art application of economic evaluation in medical education, we outline the steps to gather the necessary information to conduct an economic evaluation of simulation-based education programmes and curricula, and describe the main approaches to conducting an economic evaluation., Conclusion: A properly conducted economic evaluation can help stakeholders (i.e., programme directors, policy makers and curriculum designers) to determine the optimal use of resources in selecting the modality or method of assessment in simulation. It also helps inform broader decision making about allocation of scarce resources within an educational programme, as well as between education and clinical care. Economic evaluation in medical education research is still in its infancy, and there is significant potential for state-of-the-art application of these methods in this area., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: In 1988, the Edinburgh Declaration challenged medical teachers, curriculum designers and leaders to make an organised effort to change medical education for the better. Among a series of recommendations was a call to integrate training in science and clinical practice across a breadth of clinical contexts. The aim was to create physicians who could serve the needs of all people and provide care in a multitude of contexts. In the years since, in the numerous efforts towards integration, new models of curricula have been proposed and implemented with varying levels of success., Scope of Review: In this paper, we examine the evolution of curricular integration since the Edinburgh Declaration, and discuss theoretical advances and practical solutions. In doing so, we draw on recent consensus reports on the state of medical education, emblematic initiatives reported in the literature, and developments in education theory pertinent to the role of integrated curricula., Conclusions: Interest in integration persists despite 30 years of efforts to respond to the Edinburgh Declaration. We argue, however, that a critical shift has taken place with respect to the conception of integration, whereby empirical models support a view of integration as pertaining to both cognitive activity and curricular structure. In addition, we describe a broader definition of 'basic science' relevant to clinical practice that encompasses social and behavioural sciences, as well as knowledge derived from biomedical science., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: The impact of academic scholarship has traditionally been measured using citation-based metrics. However, citations may not be the only measure of impact. In recent years, other platforms (e.g. Twitter) have provided new tools for promoting scholarship to both academic and non-academic audiences. Alternative metrics (altmetrics) can capture non-traditional dissemination data such as attention generated on social media platforms., Objectives: The aims of this exploratory study were to characterise the relationships among altmetrics, access counts and citations in an international and pre-eminent medical education journal, and to clarify the roles of these metrics in assessing the impact of medical education academic scholarship., Methods: A database study was performed (September 2015) for all papers published in Medical Education in 2012 (n = 236) and 2013 (n = 246). Citation, altmetric and access (HTML views and PDF downloads) data were obtained from Scopus, the Altmetric Bookmarklet tool and the journal Medical Education, respectively. Pearson coefficients (r-values) between metrics of interest were then determined., Results: Twitter and Mendeley (an academic bibliography tool) were the only altmetric-tracked platforms frequently (> 50%) utilised in the dissemination of articles. Altmetric scores (composite measures of all online attention) were driven by Twitter mentions. For short and full-length articles in 2012 and 2013, both access counts and citation counts were most strongly correlated with one another, as well as with Mendeley downloads. By comparison, Twitter metrics and altmetric scores demonstrated weak to moderate correlations with both access and citation counts., Conclusions: Whereas most altmetrics showed limited correlations with readership (access counts) and impact (citations), Mendeley downloads correlated strongly with both readership and impact indices for articles published in the journal Medical Education and may therefore have potential use that is complementary to that of citations in assessment of the impact of medical education scholarship., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: There is increasing focus on how health care professionals can be trained effectively in quality improvement and patient safety principles. The morbidity and mortality round (MMR) has often been used as a tool with which to examine and teach care quality, yet little is known of its implementation and educational outcomes., Objectives: The objectives of this scoping review are to examine and summarise the literature on how the MMR is designed and delivered, and to identify how it is evaluated for effectiveness in addressing medical education outcomes., Methods: A literature search of the PubMed, MEDLINE, PsycInfo and Cochrane Library databases was conducted for articles published from 1980 to 1 June 2016. Publications in English describing the design, implementation and evaluation of MMRs were included. A total of 67 studies were identified, including eight survey-based studies, four literature reviews, one ethnographic study, three opinion papers, two qualitative observation studies and 49 case studies of education programmes with or without formal evaluation. Study outcomes were categorised using Donald Moore's framework for the evaluation of continuing medical education (CME)., Results: There is much heterogeneity within the literature regarding the implementation, delivery and goals of the MMR. Common design components included explicit programme goals and objectives, the case selection process, case presentation models and some form of case analysis. Evaluation of CME outcomes for MMR were mainly limited to learner participation, satisfaction and self-assessed changes in knowledge., Conclusions: The MMR is widely utilised as an educational tool to promote medical education, patient safety and quality improvement. Although evidence to guide the design and implementation of the MMR to achieve measurable CME outcomes remains limited, there are components associated with positive improvements to learning and performance outcomes., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Rationale, Aims and Objectives: The purpose of medical education is to produce competent and capable professional practitioners who can combine the art and science of medicine. Moreover, this process must prepare individuals to practise in a field in which knowledge is increasing and the contexts in which that knowledge is applied are changing in unpredictable ways. The 'basic sciences' are important in the training of a physician. The goal of basic science training is to learn it in a way that the material can be applied in practice. Much effort has been expended to integrate basic science and clinical training, while adding many other topics to the medical curriculum. This effort has been challenging. The aims of the paper are (1) to propose a unifying conceptual framework that facilitates knowledge integration among all levels of living systems from cell to society and (2) illustrate the organizing principles with two examples of the framework in action - cybernetic systems (with feedback) and distributed robustness., Methods: Literature related to hierarchical and holarchical frameworks was reviewed., Results: An organizing framework derived from living systems theory and spanning the range from molecular biology to health systems management was developed. The application of cybernetic systems to three levels (regulation of pancreatic beta cell production of insulin, physician adjustment of medication for glycaemic control and development and action of performance measures for diabetes care) was illustrated. Similarly distributed robustness was illustrated by the DNA damage response system and principles underlying patient safety., Conclusions: Each of the illustrated organizing principles offers a means to facilitate the weaving of basic science and clinical medicine throughout the course of study. The use of such an approach may promote systems thinking, which is a core competency for effective and capable medical practice., (Published 2016. This article is a U.S. Government work and is in the public domain in the USA.)

Context: Narrative research, an inclusive term for a range of methodologies, has rapidly become part of medical education scholarship., Concepts: In this paper we identify narrative inquiry as a particular theoretical and methodological framework within narrative research and outline its characteristics. We briefly summarise how narrative research has been used in studying medical learners' identity making in medical education., Uses of Narrative Inquiry: We then turn to the uses of narrative inquiry in studying medical learners' professional identity making. With the turn to narrative inquiry, the shift is to thinking with stories instead of about stories., Conclusions: We highlight four challenges in engaging in narrative inquiry in medical education and point toward promising future research and practice possibilities., (© 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: The study of discourses (i.e. verbal interactions or written accounts) is increasingly used in social sciences to gain insight into issues connected to discourse, such as meanings, behaviours and actions. This paper situates discourse analysis in medical education, based on a framework developed in organisational discourse analysis and widely deployed in other social science disciplines., Objectives: This paper aims to examine the constructs of 'discourse' and 'discourse analysis', and how various understandings of discourse and discourse analysis may play out in empirical and analytical settings, with a particular focus on the field of medical education., Methods: The study is based on a literature analysis of discourse analysis approaches published in Medical Education., Results: Findings suggest that empirical studies through discourse analysis can be heuristically understood in terms of the links between text, practices and meaning., Conclusions: Discourse analysis provides a more strongly supported argument when it is possible to defend claims on three levels: practice, using observational data; meaning, using ethnographic data, and text, using conversational and textual data., (© 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

This paper takes on a list of the 10 most wanted test cheaters comparable with 'most wanted' lists used by law enforcement agencies to bring attention to the issue of test cheating in medical education. The research provides an overview of test cheating in modern medical education, presents a typology of common cheaters, and provides guidelines for the prevention and detection of cheating., (© 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Conventional wisdom has it that everyone on earth is on average only six steps away from knowing any other person through 'a friend of a friend'. On a local level, however, many people experience that most of their acquaintances know each other. It is thus hard to imagine how such a highly clustered group could be so well connected to the rest of the world. In this paper, we investigate how co-authorship connects scholars in medical education and whether the six degrees of separation hypothesis also applies to the network of authors in the field., Methods: We constructed a mathematical graph from publication data obtained on the top three journals in the field and analysed it using social network analysis methods. We found Lorelei Lingard to be one centre of the network of co-authors and determined the numbers of authors who were one, two or more steps away from her. We further created a website that makes it possible to identify the shortest path from any author in the field to any other, including links to the connecting papers., Results: The analysis covered 16 653 papers by a total of 24 258 different authors. Co-authorship connected authors into 68 663 unique pairs, of which 61 937 had co-authored only one article; 67.43% of all authors were linked to each other through a 'co-author of a co-author'. The average shortest path between any two authors in this network was 5.98 (min 1, max 17); the average distance to Lorelei Lingard was 4.17 (min 1, max 10)., Conclusion: The field of medical education represents what social network analysts term 'a small world network'. Making the connections between its actors visible may provide a new perspective on social phenomena that occur in this world, including peer review, citation and conference invitations., (© 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Objective: This paper analyses how game theory can provide a framework for understanding the strategic decision-making that occurs in everyday scenarios in medical training and practice, and ultimately serves as a tool for improving the work environment and patient care. Game theory has been applied to a variety of fields outside of its native economics, but has not been thoroughly studied in the context of health care provision., Methods: The paper discusses four of the most common 'games' and applies each to a scenario in medicine to provide new insight on the incentives and drivers for certain types of behaviour and a deeper understanding of why certain results are valued more strongly than others., Conclusions: Using game theory as an integrative tool, in conjunction with good judgement and a sound knowledge base, trainees and physicians can work to better recognise where competing priorities exist, understand the motivations and interactions of the various players, and learn to adjust their approaches in order to 'change the game' when their preferred outcome is not the most likely one., (© 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Clinical supervision is essential for development of health professional students and widely recognised as a significant factor influencing student learning. Although considered important, delivery is often founded on personal experience or a series of predetermined steps that offer standardised behavioural approaches. Such a view may limit the capacity to promote individualised student learning in complex clinical environments. The objective of this review was to develop a comprehensive understanding of what is considered 'good' clinical supervision, within health student education. The literature provides many perspectives, so collation and interpretation were needed to aid development and understanding for all clinicians required to perform clinical supervision within their daily practice., Method: A comprehensive thematic literature review was carried out, which included a variety of health disciplines and geographical environments., Results: Literature addressing 'good' clinical supervision consists primarily of descriptive qualitative research comprising mostly small studies that repeated descriptions of student and supervisor opinions of 'good' supervision. Synthesis and thematic analysis of the literature resulted in four 'competency' domains perceived to inform delivery of learning-focused or 'good' clinical supervision. Domains understood to promote student learning are co-dependent and include 'to partner', 'to nurture', 'to engage' and 'to facilitate meaning'., Conclusions: Clinical supervision is a complex phenomenon and establishing a comprehensive understanding across health disciplines can influence the future health workforce. The learning-focused clinical supervision domains presented here provide an alternative perspective of clinical supervision of health students. This paper is the first step in establishing a more comprehensive understanding of learning-focused clinical supervision, which may lead to development of competencies for clinical supervision., (© 2016 John Wiley & Sons Ltd.)

Context: As a contribution to this special issue commemorating the journal's 50th volume, this paper seeks to explore directions for national licensing examinations (NLEs) in medicine. Increases in the numbers of new medical schools and the mobility of doctors across national borders mean that NLEs are becoming even more important to ensuring physician competence., Objectives: The purpose of this paper is to explore the use of NLEs in the future in the context of global changes in medical education and health care delivery., Methods: Because the literature related to NLEs is so large, we have not attempted a comprehensive review, but have focused instead on a small number of topics on which we think we have something useful to say. The paper is organised around five predicted trends for NLEs., Discussion: The first section discusses reasons why we think the use of NLEs will increase in the coming years. The second section discusses the ongoing problem of content specificity and its implications for the design of NLEs. The third section examines the evolution of large-scale, standardised cognitive assessments in NLEs and suggests some future directions. Reflecting the fact that NLEs are, increasingly, attempting to assess more than just knowledge, the fourth section addresses the future of large-scale clinical skills assessments in NLEs, predicting both increases in their use and some shifts in the nature of the stations used. The fifth section discusses workplace-based assessments, predicting increases in their use for formative assessment and identifying some limitations in their direct application in NLEs. The concluding section discusses the cost of NLEs and indulges in some further speculations about their evolution., (© 2015 John Wiley & Sons Ltd.)

Context: This paper presents a critique of current knowledge on the engagement of patients and the public, referred to here as patient and public involvement (PPI), and calls for the development of robust and theoretically informed strategies across the continuum of medical education., Methods: The study draws on a range of relevant literatures and presents PPI as a response process in relation to patient-centred learning agendas. Through reference to original research it discusses three key priorities for medical educators developing early PPI pedagogies, including: (i) the integration of evidence on PPI relevant to medical education, via a unifying corpus of literature; (ii) conceptual clarity through shared definitions of PPI in medical education, and (iii) an academically rigorous approach to managing complexity in the evaluation of PPI initiatives., Results: As a response to these challenges, the authors demonstrate how activity modelling may be used as an analytical heuristic to provide an understanding of a number of PPI systems that may interact within complex and dynamic educational contexts., Conclusion: The authors highlight the need for a range of patient voices to be evident within such work, from its generation through to dissemination, in order that patients and the public are partners and not merely objects of this endeavour. To this end, this paper has been discussed with and reviewed by our own patient and public research partners throughout the writing process., (© 2015 John Wiley & Sons Ltd.)

Context: Autoethnography is a methodology that allows clinician-educators to research their own cultures, sharing insights about their own teaching and learning journeys in ways that will resonate with others. There are few examples of autoethnographic research in medical education, and many areas would benefit from this methodology to help improve understanding of, for example, teacher-learner interactions, transitions and interprofessional development., Objectives: We wish to share this methodology so that others may consider it in their own education environments as a viable qualitative research approach to gain new insights and understandings., Methods: This paper introduces autoethnography, discusses important considerations in terms of data collection and analysis, explores ethical aspects of writing about others and considers the benefits and limitations of conducting research that includes self., Results: Autoethnography allows medical educators to increasingly engage in self-reflective narration while analysing their own cultural biographies. It moves beyond simple autobiography through the inclusion of other voices and the analytical examination of the relationships between self and others. Autoethnography has achieved its goal if it results in new insights and improvements in personal teaching practices, and if it promotes broader reflection amongst readers about their own teaching and learning environments., Conclusions: Researchers should consider autoethnography as an important methodology to help advance our understanding of the culture and practices of medical education., (© 2015 John Wiley & Sons Ltd.)

Context: Feedback is considered important in medical education. The literature is not clear about the mechanisms that contribute to its effects, which are often small to moderate and at times contradictory. A variety of variables seem to influence the impact of feedback on learning. The aim of this study was to determine which variables influence the process and outcomes of feedback in settings relevant to medical education., Methods: A myriad of studies on feedback have been conducted. To determine the most researched variables, we limited our review to meta-analyses and literature reviews published in the period from January 1986 to February 2012. According to our protocol, we first identified features of the feedback process that influence its effects and subsequently variables that influence these features. We used a chronological model of the feedback process to categorise all variables found., Results: A systematic search of ERIC, PsycINFO and MEDLINE yielded 1101 publications, which we reduced to 203, rejecting papers on six exclusion criteria. Of these, 46 met the inclusion criteria. In our four-phase model, we identified 33 variables linked to task performance (e.g. task complexity, task nature) and feedback reception (e.g. self-esteem, goal-setting behaviour) by trainees, and to observation (e.g. focus, intensity) and feedback provision (e.g. form, content) by supervisors that influence the subsequent effects of the feedback process. Variables from all phases influence the feedback process and effects, but variables that influence the quality of the observation and rating of the performance dominate the literature. There is a paucity of studies addressing other, seemingly relevant variables., Conclusions: The larger picture of variables that influence the process and outcome of feedback, relevant for medical education, shows many open spaces. We suggest that targeted studies be carried out to expand our knowledge of these important aspects of feedback in medical education., (© 2015 John Wiley & Sons Ltd.)

Context: Review studies of simulation-based education (SBE) consistently point out that theory-driven research is lacking. The literature to date is dominated by discourses of fidelity and authenticity - creating the 'real' - with a strong focus on the developing of clinical procedural skills. Little of this writing incorporates the theory and research proliferating in professional studies more broadly, which show how professional learning is embodied, relational and situated in social - material relations. A key concern for medical educators concerns how to better prepare students for the unpredictable and dynamic ambiguity of professional practice; this has stimulated the movement towards socio-material theories in education that address precisely this question., Objectives and Methods: Among the various socio-material theories that are informing new developments in professional education, complexity theory has been of particular importance for medical educators interested in updating current practices. This paper outlines key elements of complexity theory, illustrated with examples from empirical study, to argue its particular relevance for improving SBE., Results: Complexity theory can make visible important material dynamics, and their problematic consequences, that are not often noticed in simulated experiences in medical training. It also offers conceptual tools that can be put to practical use. This paper focuses on concepts of emergence, attunement, disturbance and experimentation. These suggest useful new approaches for designing simulated settings and scenarios, and for effective pedagogies before, during and following simulation sessions., Conclusions: Socio-material approaches such as complexity theory are spreading through research and practice in many aspects of professional education across disciplines. Here, we argue for the transformative potential of complexity theory in medical education using simulation as our focus. Complexity tools open questions about the socio-material contradictions inherent in SBE, draw attention to important material dynamics of emergence, and suggest practical educative ways to expand and deepen student learning., (© 2015 John Wiley & Sons Ltd.)

Context: Gender sensitivity is a crucial factor in the provision of quality health care. This paper explores acquired gendered values and attitudes among medical students through an analysis of the hidden curriculum that exists within formal medical classes and informal learning., Methods: Discourse analysis was adopted as the research method. Data were collected from the Bulletin Board System (BBS), which represented an essential communication platform among students in Taiwan before the era of Facebook. The study examined 197 gender-related postings on the BBS boards of nine of 11 universities with a medical department in Taiwan, over a period of 10 years from 2000 to 2010., Results: The five distinctive characteristics of the hidden curriculum were as follows: (i) gendered stereotypes of physiological knowledge; (ii) biased treatment of women; (iii) stereotyped gender-based division of labour; (iv) sexual harassment and a hostile environment, and (v) ridiculing of lesbian, gay, bisexual and transgender (LGBT) people. Both teachers and students co-produced a heterosexual masculine culture and sexism, including 'benevolent sexism' and 'hostile sexism'. As a result, the self-esteem and learning opportunities of female and LGBT students have been eroded., Conclusions: The paper explores gender dynamics in the context of a hidden curriculum in which heterosexual masculinity and stereotyped sexism are prevalent as norms. Both teachers and students, whether through formal medical classes or informal extracurricular interactive activities, are noted to contribute to the consolidation of such norms. The study tentatively suggests three strategies for integrating gender into medical education: (i) by separating physiological knowledge from gender stereotyping in teaching; (ii) by highlighting the importance of gender sensitivity in the language used within and outside the classroom by teachers and students, and (iii) by broadening the horizons of both teachers and students by recounting examples of the lived experiences of those who have been excluded and discriminated against, particularly members of LGBT and other minorities., (© 2015 John Wiley & Sons Ltd.)

Context: Performance assessments, such as workplace-based assessments (WBAs), represent a crucial component of assessment strategy in medical education. Persistent concerns about rater variability in performance assessments have resulted in a new field of study focusing on the cognitive processes used by raters, or more inclusively, by assessors., Methods: An international group of researchers met regularly to share and critique key findings in assessor cognition research. Through iterative discussions, they identified the prevailing approaches to assessor cognition research and noted that each of them were based on nearly disparate theoretical frameworks and literatures. This paper aims to provide a conceptual review of the different perspectives used by researchers in this field using the specific example of WBA., Results: Three distinct, but not mutually exclusive, perspectives on the origins and possible solutions to variability in assessment judgements emerged from the discussions within the group of researchers: (i) the assessor as trainable: assessors vary because they do not apply assessment criteria correctly, use varied frames of reference and make unjustified inferences; (ii) the assessor as fallible: variations arise as a result of fundamental limitations in human cognition that mean assessors are readily and haphazardly influenced by their immediate context, and (iii) the assessor as meaningfully idiosyncratic: experts are capable of making sense of highly complex and nuanced scenarios through inference and contextual sensitivity, which suggests assessor differences may represent legitimate experience-based interpretations., Conclusions: Although each of the perspectives discussed in this paper advances our understanding of assessor cognition and its impact on WBA, every perspective has its limitations. Following a discussion of areas of concordance and discordance across the perspectives, we propose a coexistent view in which researchers and practitioners utilise aspects of all three perspectives with the goal of advancing assessment quality and ultimately improving patient care., (© 2014 John Wiley & Sons Ltd.)

Context: The purpose of this paper is to provide a critical analysis of a mobile research method, the guided walk, and its potential suitability in medical education research., Methods: The Northern Ontario School of Medicine's (NOSM) longitudinal integrated clerkship served as the research context in which the guided walk method was used to explore the lived experiences of 12 Year 3 medical students undertaking their clerkship in one of eight different communities across Northern Ontario, Canada. Informed by the social constructivist research paradigm, the guided walk method was employed to answer the research question: how do Year 3 medical students at NOSM describe their clerkship experiences as encountered in their placement and living contexts? Through an inductive thematic analysis of the data, the findings provided a rich description of the guided walk from the participants' and the researcher's perspectives., Results: There were significant advantages to using the guided walk rather than other types of qualitative research approaches. The guided walk made it easier for participants to take part in the study, provided context-rich research interactions, and led to serendipitous encounters for both participants and the first author. There were also challenges and limitations associated with the guided walk method. For example, this method carries inherent challenges with reference to the safeguarding of confidentiality and anonymity for both participants and those encountered during the walk., Conclusions: The guided walk method is promising within medical education, particularly for researchers seeking to gain participants' stories in the contexts to which they refer. This method may be appropriate for use in medical education research in areas such as the evaluation and assessment of a student's clinical decision-making skills and competency development, as well as the consolidation of strategies to manage ethical and professional dilemmas., (© 2014 John Wiley & Sons Ltd.)

Context: Given that a significant portion of medical education occurs in various social settings (small groups, large classes, clinical environments), it is critical to examine how group members interact. One type of influence on these interactions is conformity, whereby an individual changes his or her own behaviour to match incorrect responses of others in a group. Conformity to peer pressure has been replicated in experimental research conducted in many countries over the last 60 years. There is newly emerging empirical evidence of this effect in medical education, suggesting that subtle motivations and pressures within a group may prevent students from challenging or questioning information that seems incorrect., Objectives: This narrative review aims to present an overview of theory and findings in research into conformity in the fields of social psychology, business, sociology and aviation theory to demonstrate its direct relevance to medical education and the health professions., Methods: We searched online databases (MEDLINE, PubMed, PsycINFO and ProQuest) from the University of Calgary catalogue. We also searched citations in articles reviewed and references provided by colleagues. We limited our narrative review to publications released between 1950 and 2012., Results: Group conformity behaviour may be one of a number of communication challenges associated with interprofessional care, and may represent a factor contributing to the burden of adverse events. This paper calls for a new programme of research into conformity in medical education that provides systematic empirical evidence of its relevance and applications in education, health care and practice., Conclusions: This review reveals decades of anecdotal and empirical evidence that conformity is a pervasive phenomenon across disciplines. Further research is needed to elucidate which situations pose the greatest risk for the occurrence of conformity, how to manage it in practice and its implications for patient safety., (© 2014 John Wiley & Sons Ltd.)

Objectives: Key-feature questions (KFQs) have been developed to assess clinical reasoning skills. The purpose of this paper is to review the published evidence on the reliability and validity of KFQs to assess clinical reasoning., Methods: A literature review was conducted by searching MEDLINE (1946-2012) and EMBASE (1980-2012) via OVID and ERIC. The following search terms were used: key feature; question or test or tests or testing or tested or exam; assess or evaluation, and case-based or case-specific. Articles not in English were eliminated., Results: The literature search resulted in 560 articles. Duplicates were eliminated, as were articles that were not relevant; nine articles that contained reliability or validity data remained. A review of the references and of citations of these articles resulted in an additional 12 articles to give a total of 21 for this review. Format, language and scoring of KFQ examinations have been studied and modified to maximise reliability. Internal consistency reliability has been reported as being between 0.49 and 0.95. Face and content validity have been shown to be moderate to high. Construct validity has been shown to be good using vector thinking processes and novice versus expert paradigms, and to discriminate between teaching methods. The very modest correlations between KFQ examinations and more general knowledge-based examinations point to differing roles for each. Importantly, the results of KFQ examinations have been shown to successfully predict future physician performance, including patient outcomes., Conclusions: Although it is inaccurate to conclude that any testing format is universally reliable or valid, published research supports the use of examinations using KFQs to assess clinical reasoning. The review identifies areas of further study, including all categories of evidence. Investigation into how examinations using KFQs integrate with other methods in a system of assessment is needed., (© 2014 John Wiley & Sons Ltd.)

Objectives: Medical education research is thriving. In recent decades, numbers of journals and publications have increased enormously, as have the number and size of medical education meetings around the world. The aim of this paper is to shed some light on the origins of this success. My central argument is that dialogue between education practice (and its teachers) and education research (and its researchers) is indispensable., Reflections: To illustrate how I have come to this perspective, I discuss two crucial developments of personal import to myself. The first is the development of assessment theory informed by both research findings and insights emerging from implementations conducted in collaboration with teachers and learners. The second is the establishment of a department of education that includes many members from the medical domain., Conclusions: Medical education is thriving because it is shaped and nourished within a community of practice of collaborating teachers, practitioners and researchers. This obviates the threat of a fissure between education research and education practice. The values of this community of practice - inclusiveness, openness, supportiveness, nurture and mentorship - are key elements for its sustainability. In pacing the development of our research in a manner that maintains this synergy, we should be mindful of the zone of proximal development of our community of practice., (© 2014 John Wiley & Sons Ltd.)

Context: The author describes a career in which he combined clinical surgery with the formal study of medical education. In the 1980s, when the author embarked on this career track, it was an uncommon pathway. Over the last 30 years there has been an exponential increase in the number of individuals who have made medical education their principal academic focus. This paper provides examples from the author's personal story and lessons derived from that experience., Process: The author outlines his experience of attaining formal training in education and concludes that this training was a foundational element in his pursuit of a career in health education research. The author describes his involvement in the transition from paper and pencil-based tests to performance-based testing in high-stakes examinations. He describes the development of a research centre in health professions education and the establishment of a simulation centre. The author's experiences in the development of an examination intended to measure technical skills, in the adoption of surgical safety checklists and in the elaboration of a programme in competency-based education are discussed., Discussion: The author describes several of the lessons learned in the course of his career in medical education. He argues that successful enterprises in scholarship in medicine are almost invariably the product of interdisciplinarity. He describes the power of a joint venture between a university and an academic hospital. He argues that the geographical footprint of an emerging centre is critical. He discusses the importance of graduate studentship in an emerging discipline and enterprise., (© 2014 John Wiley & Sons Ltd.)

Objectives: This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time., Methods: The authors' earlier work compared the 27 graduates in the first three cohorts of students undertaking the CIC with a comparison group of 45 traditionally trained HMS students; CIC graduates emerged from their clerkship year with a higher degree of patient-centredness and felt more prepared to deal with numerous domains of patient care. Between April and July 2011, at 4-6 years post-clerkship, the authors asked these original study cohorts to complete an electronic survey which included measures used in the original study. The authors also reviewed data from the National Residency Match Program to compare career paths in the two groups., Results: The response rate was 62% (42/68). The immediate post-clerkship finding that CIC students held more patient-centred attitudes was sustained over time (p < 0.035). Reflecting retrospectively on their clerkship experiences, CIC graduates continued to report that their clerkship year had better prepared them in a wide variety of domains. Graduates of the CIC attained awards and published papers at the same rates as peers, and were more likely to engage in health advocacy work. Both groups chose a wide range of residency programmes. Among those expressing a preference, no CIC graduates said they would choose a traditional clerkship, but 6 (27%) of the traditionally trained graduates said they would choose a longitudinal integrated clerkship., Conclusions: This paper indicates that benefits of longitudinal integrated clerkship training are sustained over time across multiple domains., (© 2014 John Wiley & Sons Ltd.)

Context: In current debates about professional practice and education, increasing emphasis is placed on understanding learning as a process of ongoing participation rather than one of acquiring knowledge and skills. However, although this socio-cultural view is important and useful, issues have emerged in studies of practice-based learning that point to certain oversights., Methods: Three issues are described here: (i) the limited attention paid to the importance of materiality - objects, technologies, nature, etc.-- in questions of learning; (ii) the human-centric view of practice that fails to note the relations among social and material forces, and (iii) the conflicts between ideals of evidence-based standardised models and the sociomaterial contingencies of clinical practice., Discussion: It is argued here that a socio-material approach to practice and learning offers important insights for medical education. This view is in line with a growing field of research in the materiality of everyday life, which embraces wide-ranging families of theory that can be only briefly mentioned in this short paper. The main premise they share is that social and material forces, culture, nature and technology, are enmeshed in everyday practice. Objects and humans act upon one another in ways that mutually transform their characteristics and activity. Examples from research in medical practice show how materials actively influence clinical practice, how learning itself is a material matter, how protocols are in fact temporary sociomaterial achievements, and how practices form unique and sometimes conflicting sociomaterial worlds, with diverse diagnostic and treatment approaches for the same thing., Conclusions: This discussion concludes with implications for learning in practice. What is required is a shift from an emphasis on acquiring knowledge to participating more wisely in particular situations. This focus is on learning how to attune to minor material fluctuations and surprises, how to track one's own and others' effects on 'intra-actions' and emerging effects, and how to improvise solutions., (© 2013 John Wiley & Sons Ltd.)

Objectives: This paper aims to honour the Hippocratic Oath in modern practice by providing reflections on the development of ways for doctors to know the whole person that have accrued over the five decades to the present., Methods: I present a perspective piece, which includes personal reflections and cites relevant literature., Results: Powerful role models sustained the concept of knowing the whole patient in an era of scientific medicine. Beginning in the 1980s, skills allowing ordinary doctors to know the whole patient were made transparent to learners in courses and medical school curricula. As we approach the 2020s, increasing numbers of doctors have mastered these skills and are teaching them., Conclusions: A modern way of practice is emerging; this emphasises the human side of medicine and its rewards, despite barriers such as those imposed by time limitations., (© 2013 John Wiley & Sons Ltd.)

Context: We live in a world of ethnoracial conflict. This is confirmed every day by opening and reading the newspaper. This everyday world seems far away in the pages of a medical education journal, but is it? The goal of this paper is to suggest that one need not look very far in medical education to encounter ethnoracial issues, and further, that research methods that are not ethnoracially biased must be employed to study these topics., Discussion: We will draw attention to the relevance of employing an ethical conceptual approach to research involving 'race' by demonstrating how one author researching internationally educated health professionals has put 'race' front and centre in his analysis. He does this by using a postcolonial method of analysis termed a 'doubled-research' technique that sets up categories such as 'race' but then decolonizes them to avoid essentialism or stereotyping. We compare this method to another mainstream method employed for the same topic of inquiry which has sidelined 'race' in the analysis, potentially hiding findings about ethnoracial relations involving health professionals in our 'multicultural' society. This demonstration leads to the important question of whether research methods can be epistemologically racist-a question that has been raised about conventional research on education in general. Our argument is not meant to be the last word on this topic, but the first in this journal., Conclusions: We conclude that there is an internal ethics or axiology within research perspectives and methodologies that needs to be examined where ethnoracial issues are prominent. The use of mainstream approaches to undertake research can unintentionally 'leave unsaid' central aspects of what is researched while antiracist methods such as the one described in this article can open up the data to allow for a richer and deeper understanding of the problem., (© 2013 John Wiley & Sons Ltd.)

Context: For nearly 40 years, outcome-based models have dominated programme evaluation in health professions education. However, there is increasing recognition that these models cannot address the complexities of the health professions context and studies employing alternative evaluation approaches that are appearing in the literature. A similar paradigm shift occurred over 50 years ago in the broader discipline of programme evaluation. Understanding the development of contemporary paradigms within this field provides important insights to support the evolution of programme evaluation in the health professions., Methods: In this discussion paper, we review the historical roots of programme evaluation as a discipline, demonstrating parallels with the dominant approach to evaluation in the health professions. In tracing the evolution of contemporary paradigms within this field, we demonstrate how their aim is not only to judge a programme's merit or worth, but also to generate information for curriculum designers seeking to adapt programmes to evolving contexts, and researchers seeking to generate knowledge to inform the work of others., Discussion: From this evolution, we distil seven essential elements of educational programmes that should be evaluated to achieve the stated goals. Our formulation is not a prescriptive method for conducting programme evaluation; rather, we use these elements as a guide for the development of a holistic 'programme of evaluation' that involves multiple stakeholders, uses a combination of available models and methods, and occurs throughout the life of a programme. Thus, these elements provide a roadmap for the programme evaluation process, which allows evaluators to move beyond asking whether a programme worked, to establishing how it worked, why it worked and what else happened. By engaging in this process, evaluators will generate a sound understanding of the relationships among programmes, the contexts in which they operate, and the outcomes that result from them., (© Blackwell Publishing Ltd 2013.)

Objectives: Remediation is usually offered to medical students and doctors in training who underperform on written or clinical examinations. However, there is uncertainty and conflicting evidence about the effectiveness of remediation. The aim of this systematic review was to synthesise the available evidence to clarify how and why remediation interventions may have worked in order to progress knowledge on this topic., Methods: The MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Educational Resources Information Centre), Web of Science and Scopus databases were searched for papers published from 1984 to April 2012, using the search terms 'remedial teaching', 'education', 'medical', 'undergraduate'/or 'clinical clerkship'/or 'internship and residency', 'at risk' and 'struggling'. Only studies that included an intervention, then provided retest data, and reported at least one outcome measure of satisfaction, knowledge, skills or effects on patients were eligible for inclusion. Studies of practising doctors were excluded. Data were abstracted independently in duplicate for all items. Coding differences were resolved through discussion., Results: Thirty-one of 2113 studies met the review criteria. Most studies were published after 2000 (n=24, of which 12 were published from 2009 onwards), targeted medical students (n=22) and were designed to improve performance on an immediately subsequent examination (n=22). Control or comparison groups, conceptual frameworks, adequate sample sizes and long-term follow-up measures were rare. In studies that included long-term follow-up, improvements were not sustained. Intervention designs tended to be highly complex, but their design or reporting did not enable the identification of the active components of the remedial process., Conclusions: Most remediation interventions in medical education focus on improving performance to pass a re-sit of an examination or assessment and provide no insight into what types of extra support work, or how much extra teaching is critical, in terms of developing learning. More recent studies are generally of better quality. Rigorous approaches to developing and evaluating remediation interventions are required., (© Blackwell Publishing Ltd 2013.)

Context: Phenomenography is a qualitative approach to research which has revolutionised the way that researchers and teachers think about the processes and outcomes of learning in higher education. Phenomenography has also been used successfully in medical and health care research for the last 20 years. Phenomenography provides a lens through which to view certain types of research question. It also provides direction for how to empirically carry out the research., Methods: This paper introduces phenomenography as a viable qualitative approach for use in medical education research., Results: A phenomenographic study maps the qualitatively different ways in which people experience a phenomenon. This type of study can have an important impact on, for example, patient communication, clinical practice and health care education., Conclusion: We suggest that a phenomenographic approach can be used to explore many medical education research issues, and can facilitate more solid links between research and educational development and change., (© Blackwell Publishing Ltd 2013.)

Context: At the 100th anniversary of Abraham Flexner's landmark report on medical education, critical reassessment of the direction of medical education reform evinced valuable interdisciplinary contributions from biomedicine, sociology, psychology and education theory. However, to date, philosophy has been absent from the discussion despite its long standing contribution to studies on education in other professions., Methods: This discussion paper examines how the philosophical tradition can contribute to scholarship in medical education. It begins with an explanation of the scholarly tradition of philosophy of education and its role in thinking in education more generally. It then makes links between this tradition and the context of medical education in the Flexner era of education reform. The paper then argues that this tradition is necessary to the understanding of medical education reform post-Flexner and that doctors must benefit from an education derived from this tradition in order to be able to carry out their work., Discussion: These foundations are characterised as a hidden, but always present, tradition in medical education. Two ways in which this 'lost tradition' can inform medical education theory and practice are identified: firstly, by the establishment of a public canon of medical education texts that express such a tradition, and, secondly, by the incorporation of a variety of 'signature pedagogies' exemplary of liberal education., (© Blackwell Publishing Ltd 2013.)

Objectives: This paper considers the state of the science regarding language matters in medical education, with particular attention to two informal language practices: silence and humour. Silence and humour pervade clinical training settings, although we rarely attend explicitly to them., Methods: This paper considers the treatment of these topics in our field to date and introduces a selection of the scholarship on silence and humour from other fields, including philosophy, sociology, anthropology, linguistics and rhetoric. Particular attention is paid to distilling the theoretical and methodological possibilities for an elaborated research agenda around silence and humour in medical education., Results: These two language practices assume a variety of forms and serve a range of social functions. Episodes of silence and humour are intimately tied to their relational and institutional contexts. Power often figures centrally, although not predictably., Conclusions: A rich theoretical and methodological basis exists on which to elaborate a research agenda around silence and humour in medical education. Such research promises to reveal more fully the contributions of silence and humour to socialisation in clinical training settings., (© Blackwell Publishing Ltd 2013.)

Context: Emotion in medical education rests between the idealised and the invisible, sitting uneasily at the intersection between objective fact and subjective values. Examining the different ways in which emotion is theorised within medical education is important for a number of reasons. Most significant is the possibility that ideas about emotion can inform a broader understanding of issues related to competency and professionalism., Objectives: The current paper provides an overview of three prevailing discourses of emotion in medical education and the ways in which they activate particular professional expectations about emotion in practice., Methods: A Foucauldian critical discourse analysis of the medical education literature was carried out. Keywords, phrases and metaphors related to emotion were examined for their effects in shaping medical socialisation processes., Discussion: Despite the increasing recognition over the last two decades of emotion as 'socially constructed', the view of emotion as individualised is deeply embedded in our language and conceptual frameworks. The discourses that inform our emotion talk and practice as teachers and health care professionals are important to consider for the effects they have on competence and professional identity, as well as on practitioner and patient well-being. Expanded knowledge of how emotion is 'put to work' within medical education can make visible the invisible and unexamined emotion schemas that serve to reproduce problematic professional behaviours. For this discussion, three main discourses of emotion will be identified: a physiological discourse in which emotion is described as located inside the individual as bodily states which are universally experienced; emotion as a form of competence related to skills and abilities, and a socio-cultural discourse which calls on conceptions from the humanities and social sciences and directs our attention to emotion's function in social exchanges and its role as a social, political and cultural mediator., (© Blackwell Publishing Ltd 2013.)

Context: Power and leadership are concepts that are linked. Both are studied too infrequently in medical and health care settings, given the responsibilities and opportunities doctors and other health care personnel have to exert leadership and power appropriately to foster patient-centred and health care organisational goals., Methods: This paper reviews Raven's concept of power, clarifies the bases of power that are available to doctors in different roles and provides illustrations of the application of the bases of power in medical practice. The relationship between power and leadership is explored, with an emphasis on how power and leadership are linked through the personal characteristics and competencies of the leader., Results:   Transformational leadership illustrates the incorporation and elaboration of power strategies into a principles-driven, relationship-oriented and empirically grounded form of leadership. Illustrations of the appropriate and inappropriate use of power and leadership in health care settings are provided., Conclusions: The study of power, the study of leadership and their linkage should be incorporated to a greater degree into medical education at all levels. Strategies to achieve this end are suggested., (© Blackwell Publishing Ltd 2012.)