Search

Objectives: The use of theory in research is reflected in its presence in research writing. Theory is often an ineffective presence in medical education research papers. To progress the effective use of theory in medical education, we need to understand how theory is presented in research papers. This study aims to elicit how theory is being written into general practice (GP) vocational education research papers in order to elucidate how theory might be more effectively used. This has relevance for the field of GP and for medical education more broadly., Methods: This is a scoping review of the presentation of theory in GP vocational education research published between 2013 and 2017. An interpretive approach is taken. We frame research papers as a form of narrative and draw on the theories of Aristotle's poetics and Campbell's monomyth. We seek parallels between the roles of theory in a research story and theories of characterisation., Results: A total of 23 papers were selected. Theories of 'reflective learning', 'communities of practice' and 'adult learning' were most used. Six tasks were assigned to theory: to align with a position; to identify a research problem; to serve as a vehicle for an idea; to provide a methodological tool; to interpret findings, and to represent an object of examination. The prominence of theory in the papers ranged from cameo to major roles. Depending on the way theory was used and the audience, theory had different impacts. There were parallels between the tasks assigned to theory and the roles of four of Campbell's archetypal characters. Campbell's typology offers guidance on how theory can be used in research paper 'stories'., Conclusions: Theory can be meaningfully present in the story of a research paper if it is assigned a role in a deliberate way and this is articulated. Attention to the character development of theory and its positioning in the research story is important., (© 2019 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

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.)

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.)

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.)

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.)

Introduction: Many medical schools have well-established admission pathways and programming to support Indigenous medical workforce development. Ideally, these efforts should contribute to attracting highly qualified Indigenous applicants which, in turn, may improve accessible, quality care for Indigenous people. However, it is difficult to evolve and tailor these approaches without a situated understanding of Indigenous learners' experiences. In this paper, we focus on the Canadian context, sharing Indigenous learners' stories about their journey towards and throughout medical training., Methods: The conceptual underpinnings of narrative inquiry and key principles from Indigenous methodologies were drawn upon throughout both data collection and analysis. Participants were Indigenous learners (medical students and residents) and a recently graduated physician (n = 5) from one Canadian medical school. Both spoken (formal recorded interviews) and visual (photographs) texts were used to make meaning of participants' experiences., Results: Participants' experiences during medical training showed a striking resemblance at three points in their transition to, and progression through, medical education: preparing for and applying to medical school, completing undergraduate medical training and determining specialty choice. Participants' stories revealed a tug-of-war between their identities as an Indigenous person and as a medical trainee, with these tensions sometimes compromising their perceived sense of belonging within both Indigenous and academic circles, creating, at times, a heavy burden to shoulder., Conclusion: Meaningful representation of Indigenous people in the medical workforce is about more than training additional health care providers; it requires understanding Indigenous learners and recently graduated physicians' experiences as they enter and navigate the medical profession. By amplifying their voices, we stand to gain a more holistic representation of the factors that contribute to and potentially impede the recruitment and retention of Indigenous people into the medical profession., (© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

The curriculum at the Medical School, University of Tromsø reserves 23 weeks for optional studies, including a period of 12 weeks at the end of the fifth year when the students carry out an independent study and write a short thesis. Of the first 417 doctors (graduation year 1979-89) from Tromsø 84.6% answered a postal questionnaire asking them to evaluate this part of the curriculum. These postgraduates report high levels of satisfaction with and benefit from this part of the curriculum. A total of 26.8% started working on their thesis before the final 12-week period, 32.6% had also published their study, half of these in international journals, and 75.6% found that the skills acquired during the final optional period had been useful in their subsequent work, irrespective of specialty. In conclusion, postgraduates consider their work in preparing a scientific paper as an important and integral part of medical studies.

Introduction: An understanding of social determinants of health (SDH) and patients' social circumstances is recommended to deliver contextualised care. However, the processes of patient care related to SDH in clinical settings have not been described in detail. Observable practice activities (OPAs) are a collection of learning objectives and activities that must be observed in daily practice and can be used to describe the precise processes for professionals to follow in specific situations (process OPA.) METHODS: We used a modified Delphi technique to generate expert consensus about the process OPA for patient care related to SDH in primary care settings. To reflect the opinions of various stakeholders, the expert panel comprised clinical professionals (physicians, nurses, public health nurses, social workers, pharmacists and medical clerks), residents, medical students, researchers (medical education, health care, sociology of marginalised people), support members for marginalised people and patients. The Delphi rounds were conducted online. In Round 1, a list of potentially important steps in the processes of care was distributed to panellists. The list was modified, and one new step was added. In Round 2, all steps were acknowledged with few modifications., Results: Of 63 experts recruited, 61 participated, and all participants completed the Delphi rounds. A total of 14 observable steps were identified, which were divided into four components: communication, practice, maintenance and advocacy. The importance of ongoing patient-physician relationships and collaboration with professionals and stakeholders was emphasised for the whole process of care., Discussion: This study presents the consensus of a variety of experts on the process OPA for patient care related to SDHs. Further research is warranted to investigate how this Communication-Practice-Maintenance-Advocacy framework could affect medical education, quality of patient care, and patient outcomes., (© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Globally, people with the academic and personal attributes to successfully study medicine experience disadvantages associated with sociodemographic factors. Governments have attempted to address this issue via macrolevel policies aimed at widening participation (WP) to medicine. These policies differ by country, suggesting much can be learned from examining and comparing international policy discourses of WP. Our question was: How are discourses of WP to higher and medical education positioned in the UK and Australia?, Methods: A systematic search strategy was guided by five a priori themes inspired by United Nations Sustainability Goals (2015). Seventeen policy documents (UK n = 9, Australia n = 8) published between 2008 and 2018 were identified. Analysis involved two over-arching, iterative stages: a document analysis then a Foucauldian critical discourse analysis, the latter with the aim of unveiling the power dynamics at play within policy-related discourses., Results: Discourses of social mobility and individual responsibility within a meritocracy are still paramount in the UK. In contrast, the dominant discourse in Australia is social accountability in achieving equity and workforce diversity, prioritising affirmative action and community values. Similarities between the two countries in terms of WP policy and policy levers have changed over time, linked to the divergence of internal drivers for societal change. Both nations recognise tensions inherent in striving to achieve both local and global goals, but Australia appears to prioritise community values in working towards 'nation building' whereas in the UK the focus on individuality and meritocracy at times seems at odds with achieving parity for disadvantaged individuals., Discussion: WP policies and practices are situated and contextual so caution must be taken when extrapolating lessons from one context to another. The history of a country and the nature of marginalisation in that country must be scrutinised when trying to understand what drives WP policy., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

In this article, the author provides synopses of the factors that have finally propelled health-care education and practice to join, at times reluctantly, the overarching digital transformative process that has been swept other industries over the last few decades. The key contributors and driving forces that have energized the entry of health-care education and practices are mentioned. The roles of major universities, large technology companies, and the expanding roles of Artificial Intelligence and Machine Learning are described. The projected future developments are predicted to continue to be substantial, sweeping, and forcing changes that are unprecedented. Thus, academicians and practitioners should be alerted to what the rapidly changing landscape is likely to become and accordingly take steps to manage and preserve their roles or risk be left behind or worse be forced out., (© 2022 Wiley Periodicals LLC.)

Context: Medical education is neither simple nor stable, and is highly contextualised. Hence, ways of perceiving multiple connections and complexity are fundamental when seeking to describe, understand and address concerns and questions related to change., Proposal: In response to calls in the literature, we introduce three examples of contemporary organisational theory which can be used to understand and operationalise change within medical education. These theories, institutional logics, paradox theory and complexity leadership theory, respectively, are relatively unknown in medical education. However, they provide a way of making sense of the complexity of change creatively. Specifically, they cross-cut different levels of analysis and allow us to 'zoom in' to micro levels, as well as to 'zoom out' and connect what is happening at the individual level (the micro level) to what happens at a wider institutional and even national or international level (the macro level), thereby providing a means of understanding the interactions among individuals, teams, organisations and systems. We highlight the potential value of these theories, provide a brief discussion of the few studies that have used them in medical education, and then briefly critique each theory., Conclusions: We hope that by drawing the attention of readers to the potential of these management theories, we can unlock some of the complexity of change in medical education, support new ways of thinking and open new avenues for research., (© 2020 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Student performance is a mirror of teaching quality. The pre-/post-test design allows a pragmatic approach to comparing the effects of interventions. However, the calculation of current knowledge gain scores introduces varying degrees of distortion. Here we present a new metric employing a linear weighting coefficient to reduce skewness on outcome interpretation., Methods: We compared and contrasted a number of common scores (raw and relative gain scores) with our new method on two datasets, one simulated and the other empirical from a previous intervention study (n = 180) employing a pre-/post-test design., Results: The outcomes of the common scores were clearly different, demonstrating a significant dependency on pre-test scores. Only the new metric revealed a linear relationship to the knowledge baseline, was less skewed on the upper or lower extremes, and proved well suited to allow the calculation of negative learning gains. Employing the empirical dataset, the new method also confirmed the interaction effect of teaching formats with specific subgroups of learner characteristics., Conclusion: This work introduces a new weighted metric enabling meaningful comparisons between interventions based on a linear transformation. This method will form the basis to intertwine the calculation of test performance closely with the outcome of learning as an important factor reflecting teaching quality and efficacy. Its regular use can improve the transparency of teaching activities and outcomes, contribute to forming rounded judgements of students' acquisition of knowledge and skills and enable valuable feedforward to develop and enhance curricular concepts., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Medical schools face growing pressures to develop quality improvement (QI) strategies to ensure the continuous quality of their education. To best achieve quality, both organisational processes and culture need to be oriented towards quality. Quality processes already exist at medical schools, at least externally driven by accreditation. However, the dominant culture in most medical schools is not typically oriented towards quality., Objectives: This study explores whether QI practices are recognised as such in organisations not culturally QI-oriented. Specifically, it examines faculty members' perceptions about the degree of QI implementation in their medical education programmes. Understanding this perception will inform medical school leadership on how best to use resources for a successful execution of the school's QI vision., Methods: Leaders, clinical teachers and formal teachers at 16 of the 17 Canadian medical schools were invited to complete the 'Are We Making Progress?' questionnaire of the Malcolm Baldrige National Quality Award framework, the results of which have been broadly validated. The questionnaire measures the perceived level of QI implementation within organisations using 40 statements grouped under the framework's seven domains of performance excellence., Results: A total of 491 respondents from 11 (69%) schools completed the questionnaire; 173 (35%) identified as clinical teachers, 150 (31%) as formal teachers, and 168 (34%) as leaders. Perceived QI implementation levels were low across programmes (0.70-1.90 in Rasch person measures) and for each category of respondents. This was especially true for the domains of 'Strategy', 'Measurement/analysis/knowledge management' and 'Operations'. Leaders' perceptions of QI implementation were higher than those of teachers., Conclusions: Medical schools' existing QI processes are not recognised as QI activities. For QI strategies to succeed, a programme's culture must embrace QI. In the execution of their QI visions, medical schools should spend resources on embedding quality in the organisation culture in addition to strengthening existing QI practices, especially in the domains listed above., (© 2019 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Faults commonly seen in papers on medical education in general and examination techniques in particular include: (a) Inadequate replication and neglect of the novelty effect on the results of experiments, (b) excessive reliance on internal analysis in assessing examination techniques, without seeking external evidence that the right candidates are being passed, (c) uncritical acceptance of the doctrine of a necessary core of knowledge and of pass levels derived from prior reasoning, (d) assumption that because recall and recognition methods produce different pass levels the one must necessarily be "better" than the other. It is suggested that good examiners look not for specific items of knowledge, but for evidence of a sufficient total quantity combined with sufficient judgment in the choice of what to learn, and that the one common essential attribute of good medical students and good doctors is an exceptionally high non-specific capacity for information processing.

Objectives: Several studies have measured a decline in empathy during medical training, speculating that factors within the formal, informal and hidden curricula are responsible for this phenomenon. Although the medical education literature describes the moral domain of empathy as most fundamental to the empathic response, most research into the decline has examined the cognitive, affective and behavioural domains. This study distinguishes itself by focusing on how moral empathy is affected through training., Methods: Ten medical residents from core education specialties at McMaster University participated in lightly structured interviews concerning their training experiences. Interview transcripts were analysed by way of a descriptive phenomenological approach. Analyses afforded descriptions of the way medical training influences moral empathy. These descriptions were then used to generate a verbatim theatre play that was performed for an audience of residents, educators, learners, researchers and scholars. Following the play, audience participants completed a survey to member-check the descriptions and to glean other reflective experiences in resident training that impact moral empathy. The survey results informed revisions to the codebook that was subsequently used to re-analyse the interview transcripts. This resulted in a final, refined version of the influence of training on learner moral empathy., Results: The findings suggest that a resident's sense of moral empathy relies upon the notion of an innate capacity for empathy, and is influenced by their clinical and classroom education, and specific experiences with patients during training. Importantly, these factors are rarely experienced as having a direct deleterious impact on residents' moral empathy but rather are experienced as challenges to their ability to act on their moral empathy., Conclusions: The study promotes reflection of what it means to experience empathy in the moral domain. The description offers a new perspective from which to view empathic declines that have been previously reported, while also highlighting a moral-behavioural tension that has implications for competency-based assessment and the way empathy is conceptualised in medical education., (© 2021 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: There have been significant advances in competency-based medical education (CBME) within health professions education. While most of the efforts have focused on competency, less attention has been paid to the role of confidence as a factor in preparing for practice. This paper seeks to address this deficit by exploring the role of confidence and the calibration of confidence with regard to competence., Methods: This paper presents a conceptual review of confidence and the calibration of confidence in different medical education contexts. Building from an initial literature review, the authors engaged in iterative discussions exploring divergent and convergent perspectives, which were then supplemented with targeted literature reviews. Finally, a stakeholder consultation was conducted to situate and validate the provisional findings., Results: A series of axioms were developed to guide perceptions and responses to different states of confidence in health professionals: (a) confidence can shape how we act and is optimised when it closely corresponds to reality; (b) self-confidence is task-specific, but also inextricably influenced by the individual self-conceptualisation, the surrounding system and society; (c) confidence is shaped by many external factors and the context of the situation; (d) confidence must be considered in conjunction with competence and (e) the confidence-competence ratio (CCR) changes over time. It is important to track learners' CCRs and work with them to maintain balance., Conclusion: Confidence is expressed in different ways and is shaped by a variety of modifiers. While CBME primarily focuses on competency, proportional confidence is an integral component in ensuring safe and professional practice. As such, it is important to consider both confidence and competence, as well as their relationship in CBME. The CCR can serve as a key construct in developing mindful and capable health professionals. Future research should evaluate strategies for assessing CCR, identify best practices for teaching confidence and guiding self-calibration of CCR and explore the role of CCR in continuing professional development for individuals and teams., (© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Introduction: Individual assessment disregards the team aspect of clinical work. Team assessment collapses the individual into the group. Neither is sufficient for medical education, where measures need to attend to the individual while also accounting for interactions with others. Valid and reliable measures of interdependence are critical within medical education given the collaborative manner in which patient care is provided. Medical education currently lacks a consistent approach to measuring the performance between individuals working together as part of larger healthcare team. This review's objective was to identify existing approaches to measuring this interdependence., Methods: Following Arksey & O'Malley's methodology, we conducted a scoping review in 2018 and updated it to 2020. A search strategy involving five databases located >12 000 citations. At least two reviewers independently screened titles and abstracts, screened full texts (n = 161) and performed data extraction on twenty-seven included articles. Interviews were also conducted with key informants to check if any literature was missing and assess that our interpretations made sense., Results: Eighteen of the twenty-seven articles were empirical; nine conceptual with an empirical illustration. Eighteen were quantitative; nine used mixed methods. The articles spanned five disciplines and various application contexts, from online learning to sports performance. Only two of the included articles were from the field of Medical Education. The articles conceptualised interdependence of a group, using theoretical constructs such as collaboration synergy; of a network, using constructs such as degree centrality; and of a dyad, using constructs such as synchrony. Both descriptive (eg social network analysis) and inferential (eg multi-level modelling) approaches were described., Conclusion: Efforts to measure interdependence are scarce and scattered across disciplines. Multiple theoretical concepts and inconsistent terminology may be limiting programmatic work. This review motivates the need for further study of measurement techniques, particularly those combining multiple approaches, to capture interdependence in medical education., (© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

The increasing demand for advanced genomic services has finally come to the attention of healthcare systems and stakeholders who are now eager to find creative solutions to increase the pool of genomic literate providers. Training in genetics and dysmorphology has historically been conducted as a self-driven practice in pattern recognition, ideally within a formal or informal apprenticeship supervised by a master diagnostician. In recent times, case-based learning, framed by flipped classroom pedagogy have become the preferred teaching methods for complex medical topics such as genetics and genomics. To illuminate this perspective, our article was written in honor of the teaching style and pedagogy of Dr John M. Graham Jr and his lifelong commitment to medical education and mentoring., (© 2021 Wiley Periodicals LLC.)

Introduction: 'Culture' is a word frequently invoked within medical education literature to explain challenges faced by learners in practice. While social settings and practices are widely acknowledged as critical influences on medical education, there is vast variability in how the term 'culture' is employed. This may lead to confusion, resulting in assumptions and oversights., Objective: This critical literature review aims to characterise how the term 'culture' is explicitly and implicitly conceptualised in medical education research., Methods: Four leading English language journals in the medical education field were searched in a twelve-month period for research papers or reviews that mentioned culture in title or abstract in a substantive way. A content analysis was undertaken of extracted definitions. In addition, metaphor analysis was used to identify conceptual metaphors, which were subsequently clustered thematically., Results: Our search yielded 26 papers, 8 of which contained definitions, mostly from the organisational literature. We interpreted nine conceptual metaphors related to how the term culture was employed (terroir, divider, dominant force, toxic force, obstacle, microclimate, object, brand and holdall) in four categories (unchanging, powerful, can adapt around, can be used)., Discussion: This critical review reveals that medical education as a field: 1) draws most explicitly from the organisational literature; 2) invokes culture in multiple means but in ways that privilege either acontextual human agency or all-powerful social forces; and 3) regards culture as a negative or neutral force but rarely a positive one. There is a notable absence around conceptualisations of 'culture' that allow educator, student and administrator agency but at the same time acknowledge the deep forces that various social settings and practices exert. Other literatures investigating learning cultures and cultural reflexivity focus on this nexus and may provide possible means to advance considerations of culture within medical education research., (© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Gender bias has been observed in the authorship and editorship of academic literature in varied medical specialties. This is important as peer-reviewed publications, and participation on editorial boards, are closely related to academic productivity and advancement. The aim of this paper was to examine whether gender-based disparities in authorship and editorship exist in leading medical education journals., Methods: A retrospective bibliometric review was conducted of articles published at eight different time-points across a 49-year time period (specifically: 1970, 1980, 1990, 2000, 2005, 2010, 2015 and 2019) in four leading medical education journals (Academic Medicine, BMC Medical Education, Medical Education and Medical Teacher). First and last (as a proxy for senior) author gender was determined for each article, along with the gender of the 2019 editorial board members of each journal. Chi-square tests for trend were conducted to examine variations in author gender distributions over time, and binomial tests of proportions were conducted to examine gender distributions in authorship and editorship in 2019. Logistic regression analyses were carried out to determine factors that predicted the odds of authorship by women., Results: A total of 5749 articles were included. A significant trend of increased women as first and last authors was observed across all journals. The percentage of women first authors increased from 6.6% in 1970 to 53.7% in 2019 (P < .001), and women last authors increased from 9.5% in 1970 to 46% in 2019 (P < .001). Overall, the distributions of women first authors, last authors and editorial board members in 2019 indicated greater gender parity than many other fields of medicine., Conclusions: Positive progress towards gender parity has been made in medical education scholarship. However, future research and efforts are needed to ensure the continued participation, and highlighting, of women in medical education scholarship and to address other factors which may hinder academic advancement for women in this field., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Rational, Aims, and Objectives: Qualitative research has been promoted as an important component of the evaluation of complex interventions to support the scale up and spread of health service interventions, but is currently not being maximized in practice. We aim to identify and explore the sociocultural and structural factors that impact the uses (and misuses) of qualitative research in the evaluation of complex health services interventions., Methods: We conducted a qualitative analysis of data collected in a multiple case study of the evaluation and scale up and spread of three health service intervention., Results: Our findings demonstrate the challenges of meaningfully integrating qualitative research in evaluation programmes lead by clinicians with limited qualitative expertise and operating within an environment dominated by biomedical research, even with methodological support., Conclusions: Based on these findings we encourage ongoing engagement of qualitative researchers in evaluation programmes to begin to refine our methodological understanding, while also suggesting changes to medical education and evaluation funding models to create fertile environments for interdisciplinary collaborations., (© 2020 John Wiley & Sons, Ltd.)

Context: A long-standing myth in medical education research is a divide between two different poles: research aiming to advance theory with little focus on practical applications ('ivory tower' research) and practically oriented research aiming to serve educators and decision-makers with little focus on advancing theory ('in-the-trenches' practice). We explored this myth in a sample of randomised medical education studies using Stokes' four-quadrant framework for the classification of research perspective., Methods: We searched MEDLINE, Embase, CINAHL, PsychINFO, ERIC, Web of Science and Scopus for studies in medical education using a randomised design that were published between 1 January 2018 and 31 December 2018. We used Stokes' four-quadrant framework to categorise the studies according to their use of theory, concepts and their justification for practical use. We compared medical education research published in medical education journals and clinical journals., Results: A total of 150 randomised studies were included in the analysis. The largest segment of studies (46.7%) was categorised as use-inspired basic research (Pasteur's Quadrant), closely followed by pure applied research (40.7%, Edison's Quadrant). Only a few studies were categorised as aiming to advance knowledge with no thought for practical educational application (2.0%, Bohr's Quadrant). The proportion of studies that included educational concepts and theory differed according to publication in clinical journals or medical education journals: 40.5% vs 71.8%, respectively, P < .001. There were no differences between journals with regard to the proportion of studies that included a practical educational or clinical rationale (P = .99)., Conclusion: In a large sample of studies using randomised designs, we found no evidence to support the myth that medical education research divides between two singular poles represented by 'ivory tower research' and 'in-the-trenches practice'. We did confirm prevailing assumptions regarding an emphasis on non-theoretical medical education research in clinical journals., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: The explicit, intentional and systematic application of continuous quality improvement (QI) in medical education practice and research can improve medical education and help it achieve its goals. Quality improvement and medical education share a foundation centred on learning-experiencing, reflecting, thinking and acting in continuous cycles that spiral to sustained advancement. This suggests that a QI mindset can be brought to bear on various aspects of medical education research and practice., Discussion: To explore this possibility, we turn to W. Edwards Deming's System of Profound Knowledge, widely regarded as one of the foundational frameworks in quality improvement, where he argues strongly that there are four highly interrelated elements that are required for improvement: Appreciation of a System, Theory of Knowledge, Knowledge about Variation and Knowledge of Psychology. In this article, we define and explore each of the four domains and their application in medical education, highlighting both opportunities and challenges., Conclusion: Medical educators who utilise QI in their educational practices can help create learning environments that imprint positively on learners and contribute to better outcomes in their clinical learning environments. We provide recommendations for how educators' informed use of QI can improve medical education and help it achieve its ultimate goal of improved health and health care., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Medical education and workplace learning is bound to develop through tensions between providing high quality patient care and providing training of the future specialist healthcare workforce. This paper on the Change Laboratory and the theoretical framework supporting it, shows examples on how to explore inherent and contradictory tensions in medical education and healthcare and use them as a driving force for change. We argue that the traditional tools and theories for change and fixing tensions are inadequate and therefore suggest an alternative strategy found in Cultural-Historical Activity Theory (CHAT) and the Change Laboratory method., Methods: The Change Laboratory intervention method builds on the theoretical framework of CHAT and specifically the theory of expansive learning. The Change Laboratory intervention method uses well-defined steps for participants in collaboration with researchers/facilitators to co-construct and develop new ways of going about their work practice., Results: Drawing on our own research on implementing the Change Laboratory intervention method we present two case examples of interventions in respectively a Finnish surgical unit and a Danish paediatric outpatient clinic., Conclusions: The Change Laboratory intervention offers ways to systematically leverage tensions in medical education and thus could be effective in developing and designing organisational and professional change. It is not a quick fix solution as participators must be motivated and engaged in uncovering inherent contradictions in their activity systems (workplace) and get familiar with the concepts and theory underlying the intervention and its procedures. Profound knowledge and transformative agency emerges when participants and facilitators/researchers are given the time and opportunity to analyse both historical practice, current data on practice, and organisational issues collaboratively in order to envision and redesign their practice and learning environment., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Despite the growing use of virtual patients (VPs) in medical education, few studies have explored the features and effectiveness of VP-based medical communication skills training. We undertook a systematic review to summarise the design and evaluation of VP-based medical communication skills training systems in order to identify features of successful cases., Methods: Following PRISMA guidelines, we searched four databases for studies published between 2006 and 2018. Using a refined classification scheme, we extracted data on instructional design (scenario and instructional intervention), technological design (modality and interaction), and evaluation (user experience, learning effectiveness and evaluator). We assessed the quality of studies using the Medical Education Research Study Quality Instrument (MERSQI) and the QualSyst standard assessment criteria., Results: A total of 14 studies were included for review. Of these, 85.7% (n = 12) were quantitative and 71.4% (n = 10) involved undergraduate students. The most common VP training scenario was history taking followed by the delivery of bad news. Diverse instructional interventions, including tutorials, learning activities, and feedback, were embedded in the VPs. The first-person perspective animated within-screen size VP was a popular technological feature. Most evaluations concerned the reality of simulation (for user experience) and skill in expressing empathy (as a learning outcome). Of the eight comparative studies, half reported significant attitude or skill improvements in the VP group. The distinct features of VPs shown to be effective were well-designed instructional interventions (eg, a pre-activity with a protocol-informed tutorial), and post-activity (eg, debrief or reflection), scaffolding and human feedback, but not system feedback., Conclusions: Evidence-based VP training can enable students to gain communication skills in a safe and affordable learning environment. Elaborate technology alone cannot guarantee effective learning, but evidence-based instructional interventions can facilitate its optimal use and bring about better learning outcomes., (© 2020 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Medicine is practised in complex systems. Physicians engage in clinical and operational problems that are dynamic and lack full transparency. As a consequence, the behaviour of medical systems and diseases is often unpredictable. Medical science has equipped physicians with powerful tools to favourably impact health, but a reductionist approach alone is insufficient to optimally address the complex challenges posed by illness and public health. Concepts from complexity science, such as continuous quality improvement and teamwork, strive to fill the gap between biomedical knowledge and the realities of practice. However, the superficial treatment of these systems-thinking concepts in medical education has distorted their implementation and undermined their impact. 'Systems thinking' has been conflated with 'systematic thinking'; concepts which are adaptive in nature are being taught as standardised, reductionist tools., Methods: Using concepts from complexity science, the history of science and psychology, this problem is outlined and a theoretical model of professional development is proposed., Results: This model proposes that complex problem solving and adaptive behaviour, not technical expertise, are distinguishing features of professionalism., Discussion: The impact of this model on our understanding of physician autonomy, professionalism, teamwork and continuous quality improvement is discussed. This model has significant implications for the structure and content of medical education. Strategies for enhancing medical training, including interventions in recruitment, the curriculum and evaluation, are reviewed. Such adjustments would prepare trainees to more effectively utilise biomedical knowledge and tools in the complex high-stakes reality of medical practice., (© 2019 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Introduction: A workplace-based assessment (WBA) is a learning recording device that is widely used in medical education globally. Although entrenched in medical curricula, and despite a substantial body of literature exploring them, it is not yet fully understood how WBAs play out in practice. Adopting a constructivist standpoint, we examine these assessments, in the workplace, using principles based upon naturalist inquiry, drawing from a theoretical framework based on Goffman's dramaturgical analogy for the presentation of self, and using qualitative research methods to articulate what is happening as learners complete them., Methods: Learners were voluntarily recruited to participate in the study from a single teaching hospital. Data were generated, in-situ, through observations with field notes and audiovisual recording of WBAs, along with accompanying interviews with learners., Results: Data from six learners was analysed to reveal a set of general principles-the WBA playbook. These four principles were tacit, unwritten, unofficial and learners applied them to complete their WBA proformas: (1) maintain the impression of progression, (2) manage the authenticity of the individual proforma, (3) avoid losing face with the assessor and (4) complete the proforma in an effort-efficient way. By adhering to these principles, learners expressed their understanding of their social position in their world at that time the documents were created., Discussion: This paper recognises the value of the WBA as a lived experience, and of the WBA document as a social space, where learners engage in a social performance before the readers of the proforma. Such an interpretation better represents what happens as learners undergo and record WBAs in the real-world, recognising WBAs as learner-centred, learner-driven, meaning-making phenomena. In this way, as a record of interpretation and meanings, the subjective nature of the WBA process is a strength to be harnessed, rather than a weakness to be glossed over., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: For medical students and doctors, capturing the patient's perspective is critical if the consultation is to be meaningful for both parties. Medical students are taught the import of this in their communication skills training aided by inquiring into the patient's ideas, concerns and expectations (ICE) during the consultation. Ensuring the effectiveness of those inquiries can be a challenge for different reasons. Yet apart from a handful of papers on the subject, there is little guidance on the efficacy of ICE as a communication technique and specifically how to successfully blend questions about ICE within the interaction between doctor and patient., Proposal: This paper takes a closer look at this communication technique and explores some of the interactional features of inquiries into ICE. First, the background to ICE and its emergence within the field of medical education is considered. Next the argument considers some of the contextual and pedagogical issues that inquiries into ICE gives rise to. The discussion then goes on to explore some conceptual underpinnings drawing on findings from Conversation Analysis, which provide some direction in approaching questions about what the patient thinks. Finally, the implications of the argument presented are considered in relation to the teaching and assessment of medical students with a short proposal for next steps., Conclusion: Capturing the patient's perspective through an exploration of their ideas, concerns and expectations remains a valuable approach in communication skills training in medical education. It is important, however, that ICE type inquiries are used carefully and responsively if they are to be used to improve communication with patients., (© 2022 The Author. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Health professions trainees must acquire a vast amount of clinical knowledge and skills, and a deliberate instructional design approach is needed to provide trainees with effective learning strategies. One powerful yet counterintuitive strategy that facilitates long-term learning is incorporating intentional difficulties during the learning process. Difficulties that require more effort from learners may impede short-term learning but are ultimately beneficial for long-term learning and are therefore termed Desirable Difficulties., Objectives: In this cross-cutting edge paper, we describe the Desirable Difficulty effect from three theoretical perspectives originating in different fields, discuss common evidence-based Desirable Difficulty strategies used in Health Professions Education and explore emerging research that could further optimise Desirable Difficulty-enhanced learning for health professions trainees., Methods: We synthesise theory and research from psychology, cognitive science and Health Professions Education literatures to further the understanding and application of Desirable Difficulties. We introduce three theoretical perspectives that provide a comprehensive overview of the theoretical underpinnings of the Desirable Difficulty effect: the New Theory of Disuse, the Challenge Point Framework and Cognitive Load Theory. We then illustrate how three common Desirable Difficulty strategies in medical education research-retrieval practice, spaced practice and interleaved practice-can be understood through these theoretical lenses. Finally, we provide relevant examples from the literature and explore emerging research in this area., Conclusions: This paper summarises the theory and empirical research on Desirable Difficulties during the learning process, from explaining what they are and why they may be effective to how they have been applied in different contexts. We argue that providing educators and trainees with a comprehensive theoretical and applied understanding of Desirable Difficulty will promote deliberate instructional design decisions and lead to more effective learning., (© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Objective: The aim of this paper is to provide an overview of the major quality assurance strategies, accreditation and licensure, in health professions education. It explores the nature of these regulatory processes using Brazil and the United States as examples because these large systems are at different ends of the developmental continuum. For each, it describes the tensions that arise, offers a critical synthesis of the evidence and maps out future directions., Results: Given wide variability among operating medical schools in curricular design, length of study, resources and facilities for clinical training and supervision, the nature of regulatory bodies varies considerably. Nonetheless, they share tensions related purpose and process including quality assurance versus quality improvement, outcomes versus process and continuous versus episodic evaluations and assessments. Clear evidence of effectiveness, especially for accreditation, is scarce and difficult to obtain, particularly as it relates to health outcomes., Conclusions: Regulatory processes need to be built around clear definitions of the goals for each stage of professional development, the current movement towards competency-based education and the variable durations of medical education. These changes must motivate revisions in the content and process of programmes for accreditation and licensure, complimentary efforts towards quality of care, and stimulate a significant research effort., (© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Developing a physician equipped with both technical and affective skills is crucial in ensuring quality patient care. Of these skills, nurturing empathy is a key skill that has been studied in great detail, particularly among medical undergraduates. Despite numerous studies trending the changes in empathy, the results are often contradictory or confusing. Our study aims to find what interventions are effective to inculcate empathy in both undergraduate and postgraduate medical education and suggest areas for improvement., Methods: A narrative review was conducted on the interventions in nurturing empathy in undergraduate and postgraduate medical education. Original research articles and systematic reviews with clear interventions and outcomes were included in the study., Results: A total of 44 articles were reviewed. About 44% (n = 18) of the studies used a mixture of different approaches as their interventions. Some interventions were anchored by specific topics: Seven papers focusing on communication skills, three papers on humanities, and three on arts. A majority of the interventions (60%; n = 26) were implemented over a span of time as compared to studies which suggested a one-off intervention (30%; n = 12). Of the 26 papers in which the interventions were enforced over a period of time, 62% (n = 16) indicated an increase in student empathy whereas 16% (n = 4) indicated no changes in empathy post-intervention. On the contrary, 50% (n = 6) of the one-off interventions revealed no significant change in student empathy. Jefferson Scale of Empathy (JSE) is widely used in measuring student empathy postintervention, but approximately 41% of the studies included measuring tools other than JSE., Conclusions: Pedagogical methods that invoke thought processes related to the affective domain of learning and experiential learning are more effective than the didactic methods of teaching and learning. Multimodal mixed-methods approach that combine different pedagogical interventions is more likely to bring about the desired results., (© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Entrustable professional activities (EPAs), discrete profession-specific tasks requiring integration of multiple competencies, are increasingly used to help define and inform curricula of specialty training programmes. Although guidelines exist to help guide the developmental process, deciding what logic to use to draft a preliminary EPA framework poses a crucial but often difficult first step. The logic of an EPA framework can be defined as the perspective used by its developers to break down the practice of a profession into units of professional work. This study aimed to map dominant logics and their rationales across postgraduate medical education and fellowship programmes., Methods: A scoping review using systematic searches within five electronic databases (Medline, Embase, Google Scholar, Scopus and Web of Science) was performed. Dominant logics of included papers were identified using inductive coding and iterative analysis., Results: In total, 42 studies were included. Most studies were conducted in the United States (n = 22; 52%), Canada (n = 6; 14%) and the Netherlands (n = 4; 10%). Across the reported range of specialties, family medicine (n = 4; 10%), internal medicine (n = 4; 10%), paediatrics (n = 3; 7%) and psychiatry (n = 3; 7%) were the most common. Three dominant logics could be identified, namely, 'service provision', 'procedures' and/or 'disease or patient categories'. The majority of papers (n = 37; 88%) used two or more logics when developing EPA frameworks (median = 3, range = 1-4). Disease or patient groups and service provision were the most common logics used (39% and 37%, respectively)., Conclusions: Most programmes used a combination of logics when trying to capture the essential tasks of a profession in EPAs. For each of the three dominant logics, the authors arrived at a definition and identified benefits, limitations and examples. These findings may potentially inform best practice guidelines for EPA development., (© 2022 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Competency-based assessment of learners may benefit from a more holistic, inclusive, approach for determining readiness for unsupervised practice. However, despite movements towards greater patient partnership in health care generally, inclusion of patients in postgraduate medical learners' assessment is largely absent., Methods: We conducted a scoping review to map the nature, extent and range of literature examining the inclusion (or exclusion) of patients within the assessment of postgraduate medical learners. Guided by Arskey and O'Malley's framework and informed by Levac et al. and Thomas et al., we searched two databases (MEDLINE® and Embase®) from inception until February 2021 using subheadings related to assessment, patients and postgraduate learners. Data analysis examined characteristics regarding the nature and factor influencing patient involvement in assessment., Results: We identified 41 papers spanning four decades. Some literature suggests patients are willing to be engaged in assessment, however choose not to engage when, for example, language barriers may exist. When stratified by specialty or clinical setting, the influence of factors such as gender, race, ethnicity or medical condition seems to remain consistent. Patients may participate in assessment as a stand-alone group or part of a multi-source feedback process. Patients generally provided high ratings but commented on the observed professional behaviours and communication skills in comparison with physicians who focused on medical expertise., Conclusion: Factors that influence patient involvement in assessment are multifactorial including patients' willingness themselves, language and reading-comprehension challenges and available resources for training programmes to facilitate the integration of patient assessments. These barriers however are not insurmountable. While understudied, research examining patient involvement in assessment is increasing; however, our review suggests that the extent which the unique insights will be taken up in postgraduate medical education may be dependent on assessment systems readiness and, in particular, physician readiness to partner with patients in this way., (© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Person-centeredness is a stated aim for medical education; however, studies suggest this is not being achieved. There is a gap in our understanding of how, why and in what circumstances medical education interventions that aim to develop person-centredness are successful., Methods: A realist review was conducted with a search of Medline, Embase, HMIC and ERIC databases and the grey literature using the terms 'medical education' and 'person-centred' and related synonyms. Studies that involved a planned educational intervention in medical education with data on outcomes related to person-centredness were included. The analysis focused on how and why different educational strategies interact with biomedical learner perspectives to trigger mechanisms that may or may not lead to a change in perspective towards person-centredness., Results: Sixty-one papers representing fifty-three interventions were included in the final synthesis. Nine context-intervention-mechanism-outcome configuration (CIMOc) statements generated from the data synthesis make up our refined programme theory. Where educational interventions focused on communication skills learning or experiences without person-centred theory, learners experienced dissonance with their biomedical perspective which they resolved by minimising the importance of the learning, resulting in perspective endurance. Where educational interventions applied person-centred theory to meaningful experiences and included support for sense making, learners understood the relevance of person-centeredness and felt able to process their responses to learning, resulting in perspective transformation towards person-centredness., Conclusion: Our findings offer explanations as to why communication skills-based interventions may be insufficient to develop learners' person-centredness. Integrating experiential person-centred learning with theory on why person-centredness matters to clinical practice and enabling learners to make sense of their responses to learning, may support perspective transformation towards person-centredness. Our findings offer programme and policymakers testable theory to inform the development of medical education strategies that aim to support person-centredness., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Like medicine and health care, feedback is a practice imbued with emotions: saturated with feelings relevant to one's identity and status within a given context. Often this emotional dimension of feedback is cast as an impediment to be ignored or managed. Such a perspective can be detrimental to feedback practices as emotions are fundamentally entwined with learning. In this critical review, we ask: What are the discourses of emotion in the feedback literature and what 'work' do they do?, Methods: We conducted a critical literature review of emotion and feedback in the three top journals of the field: Academic Medicine, Medical Education and Advances in Health Sciences Education. Analysis was informed by a Foucauldian critical discourse approach and involved identifying discourses of emotion and interpreting how they shape feedback practices., Findings: Of 32 papers, four overlapping discourses of emotion were identified. Emotion as physiological casts emotion as internal, biological, ever-present, immutable and often problematic. Emotion as skill positions emotion as internal, mainly cognitive and amenable to regulation. A discourse of emotion as reflexive practice infers a social and interpersonal understanding of emotions, whereas emotion as socio-cultural discourse extends the reflexive practice discourse seeing emotion as circulating within learning environments as a political force., Discussion: Drawing on scholarship within the sociology of emotions, we suggest the merits of studying emotion as inevitable (not pathological), as potentially paralysing and motivating and as situated within (and often reinforcing) a hierarchical social health care landscape. For future feedback research, we suggest shifting towards recognising the discourse-theory-practice connection with emotion in health professional education drawing from reflexive and socio-cultural discourses of emotion., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Medical students' clinical competencies are customarily assessed using convenience samples of performance from real practice. The question is how these convenience samples can be turned into purposeful samples to extrapolate students' overall competency profile at the end of medical school, particularly given the context specificity of clinical performance. In this paper, we will address this issue of inferring signs from samples using insights from the discipline of psychology., Theoretical Perspective: We adapted Smith's theory of predictor validity of universals, occupationals and relationals to the context of clinical competency assessment. Universals are characteristics required by all working individuals and therefore not context dependent. Occupationals refer to characteristics required by certain jobs but not others and therefore are dependent on task-related features of an occupation. Relationals are required in a specific organisational context with habitual ways of working together., Application: Through seven propositions, we assert that generalising from samples of assessed clinical competencies during clerkships to generic competencies (i.e., signs) is dependent on whether characteristics are universals, occupationals and relationals, with universals most and relationals least generalisable., Conclusion: When determining what types of ratings to use to evaluate medical student competence, medical education has shown too little nuance in considering the degree to which particular characteristics are likely to be generalisable, approaching the issue in an all-or-none manner. Smith's distinction between universals, occupationals and relationals offers a promising way forward that has implications for assessment, student selection and career choice., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: There are over 3.81 billion worldwide active social media (SoMe) users. SoMe are ubiquitous in medical education, with roles across undergraduate programmes, including professionalism, blended learning, well being and mentoring. Previous systematic reviews took place before recent explosions in SoMe popularity and revealed a paucity of high-quality empirical studies assessing its effectiveness in medical education. This review aimed to synthesise evidence regarding SoMe interventions in undergraduate medical education, to identify features associated with positive and negative outcomes., Methods: Authors searched 31 key terms through seven databases, in addition to references, citation and hand searching, between 16 June and 16 July 2020. Studies describing SoMe interventions and research on exposure to existing SoMe were included. Title, abstract and full paper screening were undertaken independently by two reviewers. Included papers were assessed for methodological quality using the Medical Education Research Study Quality Instrument (MERSQI) and/or the Standards for Reporting Qualitative Research (SRQR) instrument. Extracted data were synthesised using narrative synthesis., Results: 112 studies from 26 countries met inclusion criteria. Methodological quality of included studies had not significantly improved since 2013. Engagement and satisfaction with SoMe platforms in medical education are described. Students felt SoMe flattened hierarchies and improved communication with educators. SoMe use was associated with improvement in objective knowledge assessment scores and self-reported clinical and professional performance, however evidence for long term knowledge retention was limited. SoMe use was occasionally linked to adverse impacts upon mental and physical health. Professionalism was heavily investigated and considered important, though generally negative correlations between SoMe use and medical professionalism may exist., Conclusions: Social media is enjoyable for students who may improve short term knowledge retention and can aid communication between learners and educators. However, higher-quality study is required to identify longer-term impact upon knowledge and skills, provide clarification on professionalism standards and protect against harms., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Longitudinal qualitative research is an approach to research that entails generating qualitative data with the same participants over extended periods of time to understand their lived experiences as those experiences unfold. Knowing about dynamic lived experiences in medical education, that is, learning journeys with stops and starts, detours, transitions and reversals, enriches understanding of events and accomplishments along the way. The purpose of this paper is to create access points to longitudinal qualitative research in support of increasing its use in medical education., Methods: The authors explore and argue for different conceptualisations of time: analysing lived experiences through time versus analysing lived experiences cross-sectional or via 2-point follow-up studies and considering time as subjective and fluid as well as objective and fixed. They introduce applications of longitudinal qualitative research from several academic domains: investigating development and formal education; building longitudinal research relationship; and exploring interconnections between individual journeys and social structures. They provide an illustrative overview of longitudinal qualitative research in medical education, and end with practical advice, or pearls, for medical education investigators interested in using this research approach: collecting data recursively; analysing longitudinal data in three strands; addressing mutual reflexivity; using theory to illuminate time; and making a long-term commitment to longitudinal qualitative research., Conclusions: Longitudinal qualitative research stretches investigators to think differently about time and undertake more complex analyses to understand dynamic lived experiences. Research in medical education will likely be impoverished if the focus remains on time as fixed. Seeing things qualitatively through time, where time is fluid and the past, present and future interpenetrate, produces a rich understanding that can move the field forward., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

The conceptualisation of 'good' medical education research as hypothesis testing to identify universal truths that are generalisable across contexts has been challenged. Joining this conversation, the field of health professions education research is complex and contextual and there are ways of examining and reporting locally based activities and innovations, which can be of general value. This position leads to a focus on case study research (CSR), inquiry bound in time and place that generates thick descriptions and close interpretations to reach explanations. CSR has grown in sophistication in recent years and can inform practice and advance the science of medical and health professions education. The authors evaluated the current state of the science of CSR in the medical education literature by identifying and reviewing 160 papers. Most articles presented as 'case studies' were not in fact CSR. Moreover, most articles failed to go beyond a 'we did this' account. The authors explore definitions of CSR, and they examine dominant CSR methodologists, Yin, Stake and Merriam, and their respective approaches to CSR. They then set out some of the basic tenets of CSR (case definition, methods of data collection and analysis) and consider the logics of CSR (its structures, purposes, assumptions and symbols). CSR challenges are considered next (such as emic and etic perspectives; ethical complexities; generalisability; quality; and reporting and reflexivity). The authors conclude that context is a mechanism, which needs to be understood, and rigorous CSR provides the structures and criticality to do so, opening up new areas of understanding and inquiry., (© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: In medical education, there are often several didactic methods for teaching and learning a specific medical skill. For educators, there are often pragmatic reasons to decide for one or another of them, such as costs, infrastructural requirements, time expenditure or qualification of the teacher. However, a central aspect to consider is the learning outcome: Does a new method achieve a similar learning success as an established standard method? To answer this question, we need an appropriate method to assess comparability of learning outcomes., Methods: In this paper, we present two essential statistical concepts that can address the issue of comparability of learning outcomes: Equivalence and non-inferiority testing. We explain the ideas behind these concepts and illustrate them with an example data set. To clarify several concepts, we use theoretical examples from one selected field: the teaching and assessment of Basic Life Support (BLS)., Conclusions: Equivalence and non-inferiority tests can be powerful tools for comparing teaching and assessment methods. However, their correct application requires adequate knowledge about their strengths, pitfalls and application fields. The aim of this paper is to deliver this knowledge and to provide clinician researchers with a practical guidance to a successful application of these methods., (© 2020 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Qualitative research approaches are increasingly integrated into medical education research to answer relevant questions that quantitative methodologies cannot accommodate. However, researchers have found that traditional qualitative methodological approaches reflect the foundations and objectives of disciplines whose aims are recognizably different from the medical education domain of inquiry (Thorne, 2016, Interpretive description. New York, NY: Routledge). Interpretive description (ID), a widely used qualitative research method within nursing, offers an accessible and theoretically flexible approach to analysing qualitative data within medical education research. ID is an appropriate methodological alternative for medical education research, as it can address complex experiential questions while producing practical outcomes. It allows for the advancement of knowledge surrounding educational experience without sacrificing methodological integrity that long-established qualitative approaches provide., Purpose: In this paper, we present interpretive description as a useful research methodology for qualitative approaches within medical education. We then provide a toolkit for medical education researchers interested in incorporating interpretive description into their study design. We propose a coherent set of strategies for identifying analytical frameworks, sampling, data collection, analysis, rigour and the limitations of ID for medical education research. We conclude by advocating for the interpretive description approach as a viable and flexible methodology for medical education research., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre-clinical to clinical training., Methods: Eight medical students completed a social network map during a semi-structured interview within two weeks of beginning their clinical clerkships (T 0 ) and then again four months later (T 1 ). They indicated meaningful interactions that influenced their transition from pre-clinical to clinical training and discussed how these relationshipsimpacted their transition. We conducted mixed-methods analysis on this data., Results: At T 0 , eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T 1 . People from within and beyond the clinical space made up participants' social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near-peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance)., Conclusions: This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students' social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions., (© 2020 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)