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Introduction: The threshold concept framework (TCF) was first described nearly 20 years ago, but its application in the field of medical education has recently seen a significant growth of interest with a diverse range of literature published on the subject. The transformative nature of threshold concepts (TCs) offers potential for the design of learning experiences and curricula across the medical education continuum. A scoping review was conducted to map the extent of the current literature regarding TCs in medical education—to describe the types of available evidence and its focus—and identify research gaps. Methods: The review followed the JBI Manual for Evidence Synthesis approach for scoping reviews. Four databases and two additional websites were searched for articles exploring TCs in medical education. Data were analysed using quantitative and qualitative thematic approaches. A framework of conceptual change was used to synthesise the TCs identified. Results: Thirty‐six papers, spanning undergraduate, postgraduate and continuing medical education, were included in the final analysis. The most frequent application of the TCF was in the identification of TCs, which related to basic scientific knowledge, ways of thinking and ways of practising in medicine. Uncertainty, patient care, clinical reasoning and professional identify formation were themes that emerged at multiple stages of training. Several papers evaluated the use of the TCF in teaching. Conclusion: The understanding and embodiment of TCs increases in complexity across the medical education continuum, with TCs recurring with changes in clinical environment and responsibilities. This lends support to a holistic approach to curriculum design spanning all stages of training. Further research is needed to develop a consistent approach for describing and applying the TCF in medical education and to address how the TCF can be used in teaching and how threshold crossing can be measured. Understanding and embodiment of threshold concepts across the medical education continuum is argued through this review to support a holistic approach to curriculum design. [ABSTRACT FROM AUTHOR]

The authors highlight barriers to a lack of engagement with relational approaches to medical education by synthesising findings from four State of the Science papers focused on Social aspects of health professional education. [ABSTRACT FROM AUTHOR]

Introduces several articles for publication in the periodical "Medical Education." Clinical reasoning education; Value of basic science in clinical diagnosis; Peer review process for a medical education journal; Standardized patient assessment to measure professional attributes.

Background: Health care teams are increasingly forced to navigate complex challenges to achieve their collective aim of delivering high‐quality, safe patient care. The teamwork literature has struggled to develop strategies that promote effective adaptive behaviours among health care teams. In part, this challenge stems from the fact that truly collective adaptive behaviour requires members of the teams to abandon the human urge to act self‐sufficiently. Nature contains striking examples of collective behaviour as seen in social insects, fish and bird colonies. This collective behaviour is known as Swarm Intelligence (SI). SI remains poorly described in the health care team literature and its potential benefits hidden. Objective: In this cross‐cutting edge paper, I explore the principles of SI as they pertain to systemic or collective adaptation in human teams. In particular, I consider the principles of trace‐based communication and collective self‐healing and what they might offer to team adaptation researchers in medical education. Results: From a SI perspective, a solution to a problem emerges as a result of the collective action of the members of the swarm, not the individual action. This collective action is achieved via four principles: direct and indirect communication, awareness, self‐determination and collective self‐healing. Among those principles, trace‐based communication and collective self‐healing have been purposefully used by other industries to foster team adaptation. Trace‐based communication relies on leaving 'traces' in the environment to drive the behaviour of others. Collective self‐healing is the ability of the swarm to cope with failure and adapt to changes by permitting swarm members to be interchangeable. Conclusions: While allowing teams to rely on indirect communication and to be interchangeable might create discomfort to our ways of thinking, teams outside health care are demonstrating their value to advance human teamwork. SI offers a helpful analogy and a constructive language for thinking about team adaptation. Drawing analogy to swarm intelligence, Cristancho introduces the principles of collective self‐healing and trace‐based communication to offer a constructive language for thinking about team adaptation in healthcare. [ABSTRACT FROM AUTHOR]

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. The Change Laboratory intervention offers ways to leverage tensions in medical education to help design change in participants practice and learning environment. [ABSTRACT FROM AUTHOR]

Context: Competency‐based medical education has spurred the implementation of longitudinal workplace‐based assessment (WBA) programmes to track learners' development of competencies. These hinge on the appropriate use of assessment instruments by assessors. This study aimed to validate our assessment programme and specifically to explore whether assessors' beliefs and behaviours rendered the detection of progress possible. Methods: We implemented a longitudinal WBA programme in the third year of a primarily rotation‐based clerkship. The programme used the professionalism mini‐evaluation exercise (P‐MEX) to detect progress in generic competencies. We used mixed methods: a retrospective psychometric examination of student assessment data in one academic year, and a prospective focus group and interview study of assessors' beliefs and reported behaviours related to the assessment. Results: We analysed 1662 assessment forms for 186 students. We conducted interviews and focus groups with 21 assessors from different professions and disciplines. Scores were excellent from the outset (3.5–3.7/4), with no meaningful increase across blocks (average overall scores: 3.6 in block 1 versus 3.7 in blocks 2 and 3; F = 8.310, d.f. 2, p < 0.001). The main source of variance was the forms (47%) and only 1% of variance was attributable to students, which led to low generalisability across forms (Eρ2 = 0.18). Assessors reported using multiple observations to produce their assessments and were reluctant to harm students by consigning anything negative to writing. They justified the use of a consistent benchmark across time by citing the basic nature of the form or a belief that the 'competencies' assessed were in fact fixed attributes that were unlikely to change. Conclusions: Assessors may purposefully deviate from instructions in order to meet their ethical standards of good assessment. Furthermore, generic competencies may be viewed as intrinsic and fixed rather than as learnable. Implementing a longitudinal WBA programme is complex and requires careful consideration of assessors' beliefs and values. Are assessment practices ethical? This paper shows that longitudinal assessment of competencies may be complicated by assessors' beliefs [ABSTRACT FROM AUTHOR]

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. The authors demonstrate how dominant discourses in medical education literature enable the proliferation of point‐of‐care ultrasound in medical education and how these discourses make this trend appear inevitable. [ABSTRACT FROM AUTHOR]

Context: A key concern for surgical educators is to prepare students to perform in the operating room while ensuring patient safety. Recent years have seen a renewed discussion of medical education through practice theoretical and sociomaterial lenses. These lenses are introduced to understand and prepare the learner to perform in the given context. This paper takes its point of departure from practice theory by introducing a lens through which to understand learning environments in surgery. Methods: Using a multi‐site ethnographic and practice‐based design, this study investigates how aspiring surgical students are stirred into surgical practices and learn to engage as surgeons. During 70 hours of observations of medical students’ participation in the operating room, we analysed how the phenomenon of surgical learning can be perceived as instances of transformation in and among social practices. Results: By applying an analytical perspective, this article highlights the use of practice theory in surgical education, which can help to establish a firmer understanding of the learning environment and thereby help educators to improve curricula and prepare students more effectively to enter surgical training. Conclusions: The use of a practice theory adds the perspective that the education of surgeons needs to take the sayings, doings and relatings that constitute a surgical practice into account when preparing students to perform in their future workplace. In this way, surgical training can be perceived as a process of being stirred into practice. This means that one learns by participating in the practice of providing high‐quality care, where the aim is to teach students to be surgeons instead of teaching them to perform surgery. [ABSTRACT FROM AUTHOR]

Context The challenges of maintaining comprehensive banks of valid checklists make context-specific checklists for assessment of clinical procedural skills problematic. Objectives This paper reports the development of a tool which supports generic holistic assessment of clinical procedural skills. Methods We carried out a literature review, focus groups and non-participant observation of assessments with interview of participants, participant evaluation of a pilot objective structured clinical examination (OSCE), a national modified Delphi study with prior definitions of consensus and an OSCE. Participants were volunteers from a large acute teaching trust, a teaching primary care trust and a national sample of National Health Service staff. Results In total, 86 students, trainees and staff took part in the focus groups, observation of assessments and pilot OSCE, 252 in the Delphi study and 46 candidates and 50 assessors in the final OSCE. We developed a prototype tool with 5 broad categories amongst which were distributed 38 component competencies. There was > 70% agreement (our prior definition of consensus) at the first round of the Delphi study for inclusion of all categories and themes and no consensus for inclusion of additional categories or themes. Generalisability was 0.76. An OSCE based on the instrument has a predicted reliability of 0.79 with 12 stations and 1 assessor per station or 10 stations and 2 assessors per station. Conclusions This clinical procedural skills assessment tool enables reliable assessment and has content and face validity for the assessment of clinical procedural skills. We have designated it the Leicester Clinical Procedure Assessment Tool (LCAT). [ABSTRACT FROM AUTHOR]

Background A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learner's evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualise a dynamic awareness of prevailing risk and the implications of moving between zones. The importance of context We argue that clinical exposure can be consolidated by simulation where appropriate, ensuring that each learner gains the skills for safe care within the increasingly limited time available for training. To be effective, however, such simulation must be realistic, patient-focused, structured and grounded in an authentic clinical context. Challenge comes not only from technical difficulty but also from the need for interpersonal skills and professionalism within clinical encounters. Patient focused simulation Many existing simulations focus on crises, so clinicians are in a heightened state of expectation that may not reflect their usual practice. We argue that simulation should also reflect commonly occurring non-crisis situations, allowing clinicians to develop an awareness of the complex events that underpin clinical encounters. We describe a patient-focused approach to simulation, using simulated patients and inanimate models within realistic scenarios, to ground experience in authentic clinical practice and bring together the complex elements that underpin clinical events. Applications Although our argument has evolved from surgical practice and operating theatre teams, we believe it can be widely applied to the increasing number of health care professionals who perform clinical interventions. [ABSTRACT FROM AUTHOR]

Context Video has long been recognised as providing an important resource within medical education, particularly, perhaps, for training in primary health care. As a resource for research, and more specifically within qualitative social science studies of medical practice, video has proved less pervasive, despite its obvious advantages. Methods In this paper, we sketch an approach to using video to inform the analysis of medical practice and the ways in which health care is accomplished through social interaction and collaboration. Drawing on our own research, we discuss two brief examples: the first involves the use of computing technology in primary health care and the second concerns informal instruction during surgery. The examples illustrate the multimodal character of medical work, how activities are accomplished through the interplay of talk, the visual and the use of material artefacts. They also illustrate the ways in which video provides access to the complex forms of social interaction and collaboration that underpin health care. Discussion We reflect upon the research opportunities afforded by video and the ways in which video-based studies of interaction can contribute to the practice and practicalities of medicine. [ABSTRACT FROM AUTHOR]

This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life.Evidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of‘learning by doing’ in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's‘zone of proximal development’ is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of‘legitimate peripheral participation’ in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice.Simulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be usedalongsideclinical practice and linked closely with it. [ABSTRACT FROM AUTHOR]

Objectives The paper presents the findings of the evaluation of a pilot project to introduce networked information resources into clinical settings in a large NHS Trust and describes the subsequent developments of networked information within the Trust. Design The main purpose of the evaluation was to ascertain whether access to electronic journals and other resources via a networked system offered real benefits to clinical effectiveness. Setting Birmingham Heartlands and Solihull NHS Trust (Teaching). Subjects Medical and administrative staff at Birmingham and Solihull NHS Trust. Results The main conclusions of the evaluation were that: (1) appropriate location of terminals close to clinical areas is vital to ensure that best use is made of networked information resources; (2) rapid access to networked information services saves staff time and allows educational opportunities to be realized; (3) networked information resources enhance rather than replace existing information sources; (4) training and support are essential to maximizing the benefits of networked information services, and (5) such a network can support clinical decision making. Conclusions With the development of clinical governance, the clinical network has assumed even greater importance within the Trust. Timely and easy access to clinical and educational information is crucial to the practice of evidence-based medicine which underpins high quality clinical care. The evaluation led to a number of recommendations which have since been used to develop the clinical network at Birmingham Heartlands and Solihull NHS Trust. [ABSTRACT FROM AUTHOR]

Context: Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety. Method: We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations (CMOcs). Results: A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection. Conclusion: Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors. The authors present a model for the remediation of practising doctors based on an extensive realist review of the literature. [ABSTRACT FROM AUTHOR]

Context: The development of clinical reasoning (CR) in students has traditionally been left to clinical rotations, which, however, often offer limited practice and suboptimal supervision. Medical schools begin to address these limitations by organising pre-clinical CR courses. The purpose of this paper is to review the variety of approaches employed in the teaching of CR and to present a proposal to improve these practices., Methods: We conducted a narrative review of the literature on teaching CR. To that end, we searched PubMed and Web of Science for papers published until June 2014. Additional publications were identified in the references cited in the initial papers. We used theoretical considerations to characterise approaches and noted empirical findings, when available., Results: Of the 48 reviewed papers, only 24 reported empirical findings. The approaches to teaching CR were shown to vary on two dimensions. The first pertains to the way the case information is presented. The case is either unfolded to students gradually - the 'serial-cue' approach - or is presented in a 'whole-case' format. The second dimension concerns the purpose of the exercise: is its aim to help students acquire or apply knowledge, or is its purpose to teach students a way of thinking? The most prevalent approach is the serial-cue approach, perhaps because it tries to directly simulate the diagnostic activities of doctors. Evidence supporting its effectiveness is, however, lacking. There is some empirical evidence that whole-case, knowledge-oriented approaches contribute to the improvement of students' CR. However, thinking process-oriented approaches were shown to be largely ineffective., Conclusions: Based on research on how expertise develops in medicine, we argue that students in different phases of their training may benefit from different approaches to the teaching of CR., (© 2015 John Wiley & Sons Ltd.)

The article provides information on an interactive key-feature video cases presented as interactive HTML5 package (H5P) videos that allow the creators to add messages, questions, links and other interactions. Topics include elements employed in the remote format, finding on the standardised feedback utilizing the one-minute paper, and significance of the three-staged key-feature case format to medical educators.

Context: Law is slowly emerging as a core subject area in medical education, alongside content on the ethical responsibilities of doctors to protect and promote patient health and well-being. Curriculum statements have begun to advise on core content and methods for organising teaching and assessment. However, no comprehensive overview of approaches to the delivery of this law curriculum has been undertaken., Objectives: This paper reports an assessment of the nature and strength of the published evidence base for the teaching, learning and assessment of law in medical education. It also provides a thematic content overview from the best available literature on the teaching of law to medical students and on the assessment of their legal knowledge and skills., Methods: A systematic review of the evidence base was completed. Detailed scrutiny resulted in the inclusion of 31 empirical sources and 11 conceptual papers. The quality of the included material was assessed., Results: Significant gaps exist in the evidence base. Empirical studies of the teaching of law are characterised by insufficient sample sizes and a focus on individual study programmes. They rely on measures of student satisfaction and on evaluating short-term outcomes rather than assessing whether knowledge is retained and whether learning impacts on patient outcomes. Studies reveal a lack of coordination between pre- or non-clinical and clinical medico-legal education. Although evidence on the development of students' knowledge is available, much learning is distant from the practice in which its application would be tested. Law learning in clinical placements appears to be opportunistic rather than structured., Conclusions: The place of law in the curriculum remains uncertain and should be more clearly identified. A more robust knowledge base is needed to realise the aspirations behind curriculum statements on law and to enable medical students to develop sufficient legal literacy to manage challenging practice encounters. Further research is needed into effective methods of teaching, learning and assessing legal knowledge and skills during and following initial medical education., (© Blackwell Publishing Ltd 2011.)

Context During clerkships, teaching and learning in day-to-day activities occur in many moments of interaction among doctors, patients, peers and other co-workers. How people talk with one another influences their identity, their position and what they are allowed to do. This paper focuses on the opportunities and challenges of such moments of interaction between doctors and students during a clerkship characterised by short supervisory relationships. Methods This study was conducted in a 10-week internal medicine clerkship. Nine students and 10 doctors who worked with these nine students participated by regularly describing moments of interaction, using dictaphones. We performed critical discourse analysis of material sourced from a total of 184 audio diary entries and seven student debriefing interviews to reveal how participants discursively shaped the way they could think, speak and conduct themselves. Results The ways in which doctors and students posed and answered questions represented a recurrent and influential feature in the diaries. This Question and Answer dynamic revealed six discourses of Basic Learning Need, Care and Attention, Power Game, Exchange of Currency, Distance, and Equality and Reciprocity. These discourses and the interplay among them revealed both students' and doctors' frameworks of needs and expectations in a culturally defined power structure. The interplay among the discourses reflected the ways in which doctor-student interactions afforded meaningful contributions to their medical or educational practice such as in the exchange of authentic professional or personal experience. Conclusions By purposefully bringing power structures to the surface, we have addressed the complexity of learning and teaching as it occurs in day-to-day moments of interaction in a clerkship with little continuity in supervision. Both doctors and students should be supported to reflect critically on how they contribute to supervisory relationships with reference to, for example, the ways in which they ask or answer questions. [ABSTRACT FROM AUTHOR]

Context: Some medical courses in the UK have many more applicants than places and almost all applicants have the highest possible previous and predicted examination grades. The BioMedical Admissions Test (BMAT) was designed to assist in the student selection process specifically for a number of 'traditional' medical courses with clear pre-clinical and clinical phases and a strong focus on science teaching in the early years. It is intended to supplement the information provided by examination results, interviews and personal statements. This paper reports on the predictive validity of the BMAT and its predecessor, the Medical and Veterinary Admissions Test., Methods: Results from the earliest 4 years of the test (2000-2003) were matched to the pre-clinical examination results of those accepted onto the medical course at the University of Cambridge. Correlation and logistic regression analyses were performed for each cohort., Results: Section 2 of the test ('Scientific Knowledge') correlated more strongly with examination marks than did Section 1 ('Aptitude and Skills'). It also had a stronger relationship with the probability of achieving the highest examination class., Conclusions: The BMAT and its predecessor demonstrate predictive validity for the pre-clinical years of the medical course at the University of Cambridge. The test identifies important differences in skills and knowledge between candidates, not shown by their previous attainment, which predict their examination performance. It is thus a valid source of additional admissions information for medical courses with a strong scientific emphasis when previous attainment is very high.

Context: Three decades ago Elstein et al. published their classic book on medical expertise, in which they described their failure to identify superior performance by peer-nominated diagnosticians using high- and low-fidelity simulations of the everyday practice of doctors., Objective: This paper reviews the results of subsequent research, with a particular emphasis on the progress toward Elstein et al.'s goal of capturing the essence of superior clinical performance in standardised settings in order to improve clinical practice., Results: Research following publication of Elstein et al.'s book was influenced by laboratory research in cognitive psychology, which resulted in a redirection of its original focus on capturing clinical performance in practice to studies of changes in cognitive processes as functions of extended clinical experience. There is currently renewed interest in linking laboratory research with studies of the acquisition of superior (expert) performance in the clinic., Conclusions: Research on medical expertise and simulation training in technical procedures and diagnosis provide exciting opportunities for establishing translational research on the acquisition of superior (expert) performance in the clinic by capturing it with representative tasks in the laboratory, reproducing it for experimental analysis, and developing training activities, such as deliberate practice, that can induce measurable improvements in performance in the clinic.

Context: China has a long tradition of education and medicine. However, limited economic conditions and a huge population mean that further development of medical education in China must be tailored to meet the country's needs., Objectives: The aim of this paper is to describe current medical education practice in China with reference to the general and historical purposes of education in China and how they have affected and continue to affect student learning. Reference is also made to both Western medicine and traditional Chinese medicine., Methods: It is argued that traditional educational practices in China have encouraged rote learning and that creativity is not cultivated. This affects the way many Chinese students learn medicine. Since 1949, the Chinese medical education system has developed according to its own needs. The current system for training medical students is complex, with medical school curricula lasting 3-8 years. However, medical education reform is taking place and new teaching methods are being introduced in some schools., Discussion: Medical education is important to China's large population. The undergraduate medical education system is being streamlined and national standards are being established. Innovations in medical education have recently been encouraged and supported, including the adoption of problem-based learning. It is important that the momentum is kept up so that the health care of a fifth of the world's population is assured.

Background: Narrative inquiry is a form of qualitative research that takes story as either its raw data or its product. Science and narrative can be seen as two kinds of knowing, reflected in the distinction between evidence-based medicine derived from population studies and narrative-based medicine focused upon the single case. A similar tension exists in the field of narrative inquiry between cognitive-orientated analytical methods and affective-orientated methods of synthesis., Aims: This paper aims to make sense of narrative inquiry in clinical education through definition of 'narrative', articulation of a typology of narrative research approaches, and critical examination in particular of analytical methods, the dominant approach in the literature. The typology is illustrated by research examples, and the role of medical education in developing expertise in narrative inquiry is discussed. An argument is made that the tension between analysis of the structure of stories and empathic use of stories can be seen as productive, stimulating expertise encompassing both approaches., Discussion: Analytical methods tend to lose the concrete story and its emotional impact to abstract categorizations, which may claim explanatory value but often remain descriptive. Stemming from discomfort with more integrative methods derived from the humanities, a science-orientated medical education may privilege analytical methods over approaches of synthesis. Medical education can redress this imbalance through attention to 'thinking with stories' to gain empathy for a patient's experience of illness. Such an approach can complement understanding of story as discourse - how narratives may be used rhetorically to manage both social interactions and identity.

Objectives There is currently little theoretically informed exploration of how non-traditional clinical placement programmes that are longitudinal, immersive, based on community-engaged education principles and located in rural and remote settings may contribute to medical student learning. This paper aims to theoretically illustrate the pedagogical and socio-cultural underpinnings of student learning within a longitudinal, integrated, community-engaged rural placement. Methods Data collected using semi-structured interviews with medical students, their supervisors and other health clinicians participating in a longitudinal rural placement programme were analysed using framework analysis. Data interpretation was informed by the theory of social learning systems (SLSs). Results In a longitudinal, rural clinical placement students participate in an SLS with distinct yet interrelated learning spaces that contain embedded communities of practice (CoPs). These spaces are characterised by varying degrees of formality, membership and interaction, and different learning opportunities and experiences. They are situated within and shaped by a unique geography of place comprising the physical and social features of the placement setting. Within these learning spaces, students acquire clinical knowledge, skills and competencies, professional attitudes, behaviours and professional values. The process of connectivity helps explain how students access and cross the boundaries between these learning spaces and develop a more complex sense of professional identity. Conclusions Longitudinal, integrated clinical placement models can be understood as SLSs comprising synergistic and complementary learning spaces, in which students engage and participate in multiple CoPs. This occurs in a context shaped by unique influences of the geography of place. This engagement provides for a range of student learning experiences, which contribute to clinical learning and the development of a more sophisticated professional identity. A range of pedagogical and practical strategies can be embedded within this SLS to enhance student learning. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 1161-1173 Context General practice supervisors are said to serve as the cornerstones of general practice postgraduate education and therefore it is important to clearly define their roles and what makes them effective. The commonly used definition of a supervisor is not primarily based on general practice and does not cover aspects predicted to be important according to work-based learning theory. Methods We searched for papers published between 1991 and 2011 inclusive, categorised them according to whether they provided empirical evidence, descriptions or recommendations, open-coded the empirical evidence, and used the resulting coding scheme as an analytic framework within which to present a narrative summary of findings. Results Recommendations and descriptions far outweighed empirical evidence, which showed how supervisors intertwined clinical and educational activities and formed educational alliances with resident doctors that provided a foundation for learning. Residents needed a balance of challenge, usually provided by patients, and support, provided by supervisors. Supervisors established learning environments, assessed residents' learning needs, facilitated learning, monitored the content and process of learning and the well-being of residents, and summarised learning in ways that turned 'know that' into 'know how'. Conclusions General practice must be expert in ensuring patients are well cared for 'by proxy' and in giving residents just the right amount of support they need to face the challenges posed by those patients. As general practice responds to contemporary clinical demands and rising numbers of undergraduate medical students, it is essential that the ability of general practice supervisors to develop and sustain supportive supervisory relationships with residents is preserved. [ABSTRACT FROM AUTHOR]

Medical Education 2011: : 69-80 Trainees in undergraduate and postgraduate medical education engage in multiple transitions as part of the educational process, including many transitions that occur on both periodic and daily bases within medical education programmes. The clinical rotation, based on either a medical discipline or clinical care setting and occurring over a predetermined, short period of time, is a deeply entrenched educational approach with its roots in Abraham Flexner's seminal report. Many assumptions about the presumed benefits of clinical rotations have become pervasive despite a lack of empirical evidence on their optimal timing and structure, and on how transitions between clinical rotations should occur. In this paper, we examine the issue of rotational transitions from the three perspectives of sociology, learning theory, and the improvement of quality and safety. Discussion from the sociological perspective addresses the need for much greater attention to interprofessional relationships and professional development, whereas that from the learning theory perspective examines the gap between what is known from pedagogical and cognitive science and what is currently practised (learning theory). Discussion from the perspective of improving quality and safety refers to the critical need to embed trainees in functional clinical microsystems as meaningful participants. Research is urgently needed on the effects of transitions on trainees, faculty staff, non-doctor health care providers and patients in order to optimise future competency-based training models and confirm or refute current assumptions. [ABSTRACT FROM AUTHOR]

Context Reflective practice has been suggested to be an important instrument in improving clinical judgement and developing medical expertise. Empirical evidence supporting this suggestion, however, is absent. This paper reports on an experiment conducted to study the effects of reflective practice on diagnostic accuracy. Methods Participants were 42 internal medicine residents in hospitals in 2 states in the northeast of Brazil. They diagnosed 16 clinical cases. The experiment employed a repeated measures design, with 2 independent variables: the complexity of clinical cases (simple or complex), and the reasoning approach induced to diagnose the case (participants were instructed to diagnose each case either through pattern recognition or reflective reasoning). The dependent variable was the accuracy of the diagnosis provided for each case. All participants participated in each of the 2 levels of both independent variables. Results A main effect of case complexity emerged. There was no statistically significant main effect of reflective practice. However, a significant interaction effect was found between case complexity and mode of processing (F[1,41] = 4.48, P < 0.05), indicating that although reflective practice did not make a difference to accuracy of diagnosis in simple cases, it had a positive effect when diagnosing complex cases. Conclusions Reflective practice had a positive effect on diagnosis of complex, unusual cases. Non-analytical reasoning was shown to be as effective as reflective reasoning for diagnosing routine clinical cases. Findings support the idea that reflective practice may particularly improve diagnoses in situations of uncertainty and uniqueness, reducing diagnostic errors. [ABSTRACT FROM AUTHOR]

Objectives The aim of this review was to evaluate the effectiveness of medical skills laboratories or simulators. In particular, it aimed to determine if performance in medical skills laboratories is transferable to actual clinical performance and maintained over time. Methods A range of databases was utilised to search for relevant papers published from 1998 to June 2006. Articles were included in the review if they met a number of criteria that included the evaluation of a skills laboratory or simulator for the purpose of procedural skills training, that participants were either undergraduate medical students or postgraduate medical trainees, and that the study used a randomised, controlled trial (RCT) research design in evaluation. Results A total of 44 RCTs were identified for inclusion in the review. Overall, 32 (70%) studies reported that simulator training significantly improved procedural skills performance in comparison with standard or no training. Twenty (45%) RCTs assessed the transfer of simulator performance to clinical skills performance; however, 8 of these used animal models, not real patients. Only 2 studies assessed the maintenance of skills post-intervention, both at 4-month follow-up periods. Conclusions Medical skills laboratories do lead to improvement in procedural skills compared with standard or no training at all when assessed by simulator performance and immediately post-training. However, there is a lack of well designed trials addressing the crucial issues of transferability to clinical practice and retention of skills over time. Further research must be carried out to address these matters if medical skills laboratories are to remain an integral component of medical education. [ABSTRACT FROM AUTHOR]

Introduction Observation, including identification of key pieces of data, pattern recognition, and interpretation of significance and meaning, is a key element in medical decision making. Clinical observation is taught primarily through preceptor modelling during the all-important clinical years. No single method exists for communicating these skills, and medical educators have periodically experimented with using arts-based training to hone observational acuity. The purpose of this qualitative study was to better understand the similarities and differences between arts-based and clinical teaching approaches to convey observation and pattern recognition skills. Method A total of 38 Year 3 students participated in either small group training with clinical photographs and paper cases (group 1), or small group training using art plus dance (group 2), both consisting of 3 2-hour sessions over a 6-month period. Findings Students in both conditions found value in the training they received and, by both self- and instructor-report, appeared to hone observation skills and improve pattern recognition. The clinically based condition appeared to have been particularly successful in conveying pattern recognition concepts to students, probably because patterns presented in this condition had specific correspondence with actual clinical situations, whereas patterns in art could not be generalised so easily to patients. In the arts-based conditions, students also developed skills in emotional recognition, cultivation of empathy, identification of story and narrative, and awareness of multiple perspectives. Conclusion The interventions studied were naturally complementary and, taken together, can bring greater texture to the process of teaching clinical medicine by helping us see a more complete ‘picture’ of the patient. [ABSTRACT FROM AUTHOR]

This paper investigates how students vary in their conception and engagement of the diagnostic process. The research question is whether it is possible to isolate appropriate sources of variation that are sufficiently psychometrically and conceptually robust for modelling purposes. Eleven such sources of variation are reported, together with an associated common-factor empirical model that is readily interpretable in conceptual terms.

Context: Patient–student relationships are at the heart of Longitudinal Integrated Clerkships (LICs). Outcomes for students and preceptors are beneficial, but patient outcomes remain unclear. This systematic literature review explored the current evidence base of patient outcomes in an LIC. Patient outcomes were defined as issues related to patient safety, clinical effectiveness or patient experience. Methods: Seven bibliographic databases were searched. A wider search strategy included a hand search of three medical education journals' previous issues and backward/forward citation searching of included studies and of a relevant systematic review. Included studies were quality appraised and assessed for their strength and level of evidence. A qualitative data synthesis was performed. Results: Databases searches identified 7237 titles. Following the removal of duplicates, titles and abstracts were reviewed against the inclusion criteria. Forty‐eight studies had a full‐text review. Nineteen met the inclusion criteria. Seven studies were included from the wider search strategy. From the 26 included studies, two major themes were identified. (1) 'A trusting patient‐student relationship' contains the sub‐themes: 'care and compassion', 'patient education and empowerment' and 'the loss of the student as 'my' doctor'. (2) 'The student acts as an agent of change for the patient' contains the sub‐themes: 'patient advocacy', 'supporting the patient to navigate the healthcare system', 'communication between patient and healthcare professional' and 'enhancement of preceptors' care, healthcare services and communities'. Conclusions: LICs provide educational continuity allowing the creation of a trusting patient–student relationship. This relationship leads to students becoming agents of change for patients by enhancing patient outcomes. This review provides further evidence on the benefits of having an LIC as part of the medical education curricula and implications for its successful delivery. Further research is needed to explore educationally induced benefits for patients and look at objective assessments of patient health outcomes. Longitudinal Integrated Clerkships provide educational continuity, enabling trusting patient‐student relationships that lead students to become agents of change and enhance patient outcomes. [ABSTRACT FROM AUTHOR]

A central task in clinical teaching is organization of the students' experience in clinical perception--the ability to observe, to recognize, to discriminate and to interpret clinical evidence. We cannot teach sensory perceptual experience. Students must experience the clinical phenomena for themselves. But we can ensure that what the student experiences is most likely to be turned into clinical learning. This paper dissects the learning task in order to derive plans for teaching clinical perception. A major purpose is to encourage closer study of physical examination, which has largely been upstaged by investigations. Students learn inductively from their experiences of examining patients, cumulating a 'clinical memory' of images of patients with diseases. Reflection on that experience with the clinical teacher translates the sensory evidence into words. Teachers link the clinical observations of 'disease in patients' with previously learned images of 'diseases in organs', to ensure that clinical features and underlying basic science knowledge are clearly integrated. Perception is an active process, not a passive reception of observational data. Learning and teaching clinical perception uses both the student's direct 'sense' experiences and the teacher's guidance in 'making sense' of them.

This paper compares ethics programmes in clinical education in two medical schools in the Netherlands. Ethics education in the University of Maastricht is case oriented, whereas the emphasis in ethics teaching in the Catholic University of Nijmegen is focused on the methods of ethics and moral reasoning. The general objectives, format and evaluation are discussed. Both programmes assume that in clinical decision-making normative and technical issues are intertwined; if a normative dimension is intrinsic to medical practice itself, students should learn during clinical training how to explicate and evaluate the moral quandaries of their profession. The positive characteristics of the Maastricht programme (student-centred approach, relevant cases, team-teaching of ethicist and clinician), if combined with those of the Nijmegen programme (a coherent theoretical framework and method for case analysis and interpretation), would create a new, powerful model for clinical ethics teaching. In a recent report such a model is advocated for all Dutch medical schools.

During the course of a larger study aimed at relating staffing levels of junior doctors in general medicine to the safety of the care provided, it became clear that consultant doctors considered the quality of their junior staff as being at least as important as the quantity. This paper describes several attempts to develop a feasible and valid method of measuring the quality of senior house officers (SHOs) and registrars using routinely available data. Having rejected three methods and had difficulties with three other methods, a modified Delphi survey was used to explore the extent to which consultants agreed on the key attributes of a high quality SHO or registrar. Sixty-seven (60%) of all consultants in the South-West Thames and Trent regions responded to two rounds of questionnaires which revealed communication skills as being consistently the most significant factor. This was confirmed in a second, anonymous survey of 198 (78%) SHO and registrar posts in the North-West Thames region. It also became clear that consultants viewed the quality of their own SHOs and registrars as generally high. This being so it is argued that the requirement to adjust for quality, when comparing SHO and registrar levels between hospitals, is of minor importance. These results also suggest that the explicit teaching of communication skills should have a high priority in undergraduate and postgraduate education.

The authors comment on the paper "Block Versus Longitudinal Integrated Clerkships: Students' Views of Rural Clinical Supervision" by M. Whitey et al. They discuss clinical placements as the foundation of health professional education and a requirement of accrediting organizations. They compare two structures for placement in a rural setting: shorter blocks and longer integrated placements.

Provides insights on the difficulty in medical humanities as states in a paper by Delese Wear and Julie Aultman. Discussion on student resistance to learning especially about gender, sexual identity and race; Challenges to the theoretical basis of narrative medicine and issues of power in the classroom.

Context Ethnic minority students find that their ethnicity negatively affects the evaluation of their capacities and their feelings in medical school. This study tests whether ethnic minority and majority students differ in their 'self‐regulatory focus' in clinical training, that is, their ways to approach goals, due to differences in social learning experiences. Self‐regulatory focus consists of a promotion and prevention focus. People who are prone to stereotypes and unfair treatments are more likely to have a prevention focus and conceal certain identity aspects. The objectives of the study are to test whether ethnic minority students, as compared with ethnic majority students, are equally likely to have a promotion focus, but more likely to have a prevention focus in clinical training due to more negative social learning experiences (Hypothesis 1), and whether the relationship between student ethnicity and clinical evaluations can be explained by students' gender, social learning experiences, self‐regulatory focus and impression management (Hypothesis 2). Methods: Survey and clinical evaluation data of 312 (71.2% female) clerks were collected and grouped into 215 ethnic majority (69.4%) and 95 ethnic minority students (30.6%). Students' social learning experiences were measured as perceptions of unfair treatment, trust in supervisors and social academic fit. Self‐regulatory focus (general and work specific) and impression management were also measured. A parallel mediation model (Hypothesis 1) and hierarchical multiple regression analyses were used (Hypothesis 2). Results: Ethnic minority students had higher perceptions of unfair treatment and lower trust in their supervisors in clinical training. They were more prevention focused in clinical training, but this was not mediated by having more negative social learning experiences. Lower clinical evaluations for ethnic minority students were unexplained. Promotion focus in clinical training and trust in supervisors positively relate to clinical grades. Conclusion: Student ethnicity predicts social learning experiences, self‐regulatory focus and grades in clinical training. The hidden curriculum plausibly plays a role here. van Andel et al. demonstrate that systematic differences between ethnic minority and majority students can be predicted based on social learning experiences, self‐regulatory focus and clinical grades. [ABSTRACT FROM AUTHOR]

Objective: The participation of students from both undergraduate medical education (UGME) and postgraduate medical education (PGME) in independent patient care contributes to the development of knowledge, skills and the professional identity of students. A continuing collaboration between students and their preceptor might contribute to opportunities for students to independently provide patient care. In this systematic review, we aim to evaluate whether longitudinal training models facilitate the independent practice of students and what characteristics of longitudinal training models contribute to this process. Method: This systematic review was performed according to the PRISMA guidelines. In May 2020, we performed a search in three databases. Articles evaluating the impact of longitudinal training models on the independent practice of students from both UGME and PGME programmes were eligible for the study. A total of 68 articles were included in the study. Quality of the included studies was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Results: Both UGME and PGME students in longitudinal training models are more frequently allowed to provide patient care independently when compared with their block model peers, and they also feel better prepared for independent practice at the end of their training programme. Several factors related to longitudinal training models stimulate opportunities for students to work independently. The most important factors in this process are the longitudinal relationships with preceptors and with the health care team. Conclusion: Due to the ongoing collaboration between students and their preceptor, they develop an intensive and supportive mutual relationship, allowing for the development of a safe learning environment. As a result, the professional development of students is fostered, and students gradually become part of the health care team, allowing them the opportunity to engage in independent patient care. This work demonstrates how longitudinal rotation models can make an important contribution to the entrustment of patient care to students. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 795-806 Context Many academic medical centres (AMCs) have introduced institutional policies, changed processes of care and implemented new technologies to improve health care quality. The impact of such changes on medical education has received little attention. We examine the impact of computerised provider order entry (CPOE) on the educational experiences of medical trainees who work and train in AMCs. Methods We conducted semi-structured interviews of postgraduate trainees and attending physicians in internal medicine at five AMCs (two with CPOE, three without CPOE). Trainees routinely rotate from CPOE to non-CPOE AMCs, whereas some attending physicians work at both types of AMC and are therefore well positioned to reflect on differences between CPOE and non-CPOE learning environments. Data collection and analysis used grounded theory methods. We sampled purposively until we achieved theoretical saturation. Results Our study included 11 residents and six attending physicians. Computerised provider order entry had both positive and negative impacts on five aspects of postgraduate training: (i) learning (better for medication interactions and availability of learning resources; worse for learning medication doses); (ii) teaching (more medication information available to enhance case discussions; fewer face-to-face teaching opportunities); (iii) feedback (improved ability to observe medication ordering behaviours to inform feedback; less provision of direct feedback); (iv) clinical supervision (facilitates efficient and safe supervision from a distance; may impede trainee independence), and (v) trainee assessment (increased opportunity to assess clinical decision-making and organisational skills). Conclusions We identify five key educational themes that are positively and negatively impacted by CPOE. These themes form a conceptual framework that could be applied to define the educational impact of other health care quality and patient safety practices. This will help educators to identify educational opportunities and protect the safety of the training experience of residents in AMCs. [ABSTRACT FROM AUTHOR]

Introduction: Workplace- based learning conversations can be a good opportunity for supervisors and trainees to learn from each other. When both professionals discuss their specific knowledge openly with each other, learning conversations may be a useful educational tool, for instance for learning how to apply evidence- based medicine (EBM) in the workplace. We do, however, need a better understanding of how the exchange of knowledge provides opportunities for such bidirectional learning. The aim of this study was therefore to analyse how trainees and supervisors currently handle bidirectional learning opportunities by describing in detail how supervisors respond to knowledge expressed by trainees during a learning conversation. Method: We video- recorded learning conversations between supervisors and trainees in general practice (GP). Within these learning conversations, EBM discussions on medical topics were selected and transcribed. We then identified, analysed using Conversation Analysis (CA) and categorised each expression of knowledge by the trainee and the supervisor's subsequent response. Results: We found that when a trainee expresses knowledge during the learning conversation, supervisors either (a) refute the expressed knowledge, (b) immediately suggest an alternative or (c) pose (additional) questions. These responses have consequences for the learning opportunities of both trainee and supervisor: it is only when supervisors pose further questions that trainees are encouraged to elaborate on their knowledge, leading to a bidirectional learning opportunity. Discussion: Improving EBM learning opportunities for both supervisors and trainees requires more than simply instructing trainees to express knowledge- based-- for instance-- on recent evidence more often. Inflexible institutional roles related to historical claims of supervisors' epistemic authority hamper bidirectional learning. Posing open questions during learning conversations enhances the flexibility of institutional roles while also creating bidirectional learning opportunities. [ABSTRACT FROM AUTHOR]

Objectives To determine the feasibility and effectiveness of shared hospital and general practice clinical teaching for medical undergraduates. Design A multifaceted approach employing quantitative and qualitative techniques. Setting All medical schools in North Thames Region. Subjects Students, GP tutors and hospital specialists. Results The model was successfully adopted in a broad range of clinical specialties in all of the participating medical schools, resulting in a doubling of the involvement of general practice in clinical teaching. Participating students provided an overwhelmingly positive evaluation of the attachments and there was a clear perception of benefit amongst the participating GPs. However, the views of the participating hospital clinicians were less positive and the true nature and extent of the educational impact proved difficult to assess. Conclusions This model of collaborative clinical teaching between hospital and general practice can be implemented in accordance with the project’s key aims, but the enthusiastic involvement of hospital clinicians may be difficult to secure. [ABSTRACT FROM AUTHOR]

Introduction: Peer learning is increasingly used for healthcare students in the clinical setting. However, as peer learning between students involves students taking a teaching role, it is unclear what the supervisor's role then becomes. It is vital to determine the role of the supervisor in student peer learning to ensure high quality learning and patient safety. Methods: Semi‐structured interviews were performed with 15 student nurse supervisors (nurses and assistant nurses) from two hospital wards that practice peer learning to investigate the different ways clinical supervisors view their role in students' peer learning. Transcribed data were coded and analysed using a phenomenographic approach. Results: Four hierarchical levels of the supervisor's understanding of their role in students' peer learning were identified: the teacher; the facilitator; the stimulator; and the team player. These categories represent an increasingly inclusive view of which people present on the ward play a role in enabling effective peer learning. Conclusions: The various understandings of supervisor roles have implications for how supervision of peer learning could be implemented in the future. This interview study reveals different ways in which supervisors view their role in supporting peer learning: teacher; facilitator; stimulator; and team player. [ABSTRACT FROM AUTHOR]

Objectives: It remains unclear how medical educators can more effectively bridge the gap between trainees' intolerance of uncertainty and the tolerance that experienced physicians demonstrate in practice. Exploring how experienced clinicians experience, appraise and respond to discomfort arising from uncertainty could provide new insights regarding the kinds of behaviours we are trying to help trainees achieve. Methods: We used a constructivist grounded theory approach to explore how emergency medicine faculty experienced, managed and responded to discomfort in settings of uncertainty. Using a critical incident technique, we asked participants to describe case‐based experiences of uncertainty immediately following a clinical shift. We used probing questions to explore cognitive, emotional and somatic manifestations of discomfort, how participants had appraised and responded to these cues, and how they had used available resources to act in these moments of uncertainty. Two investigators coded the data line by line using constant comparative analysis and organised transcripts into focused codes. The entire research team discussed relationships between codes and categories, and developed a conceptual framework that reflected the possible relationships between themes. Results: Participants identified varying levels of discomfort in their case descriptions. They described multiple cues alerting them to problems that were evolving in unexpected ways or problems with aspects of management that were beyond their abilities. Discomfort served as a trigger for participants to monitor a situation with greater attention and to proceed more intentionally. It also served as a prompt for participants to think deliberately about the types of human and material resources they might call upon strategically to manage these uncertain situations. Conclusions: Discomfort served as a dynamic means to manage and respond to uncertainty. To be 'tolerant' of uncertainty thus requires clinicians to embrace discomfort as a powerful tool with which to grapple with the complex problems pervasive in clinical practice. The authors report how practicing clinicians experience, appraise, and respond to discomfort arising from uncertainty, describing it as a trigger for instigating strategic management of uncertainty. [ABSTRACT FROM AUTHOR]

The authors suggest that merging patient co‐designed simulation with patient‐present teaching may help the spotlight remain on patient‐centred care during student‐centred learning. [ABSTRACT FROM AUTHOR]

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. The authors turn to Deming for a #QI framework to support continuous improvement of #MedEd practice and scholarship. [ABSTRACT FROM AUTHOR]

Context: Having succeeded in being selected for medical school, medical students are not always familiar with failure and yet they are expected to graduate prepared to effectively function in the failure‐burdened arena of clinical medicine. Lacking in the developing literature on learners and failure is an exploration of how this transformation is accomplished. The purpose of this study was to examine how medical students perceive and experience failure during their medical school training. Method: We used a qualitative description methodology to probe the failure experiences of medical students attending a Canadian medical school. Participants were provided with the broad definition of failure used in this research: 'deviation from expected and desired results.'In total, 12 students were sampled, three from each of the 4 years of study, and participated in individual, semi‐structured interviews that were analysed using thematic analysis to identify and describe core themes. Results: At the start of medical school, students admitted limited experience with failure; their early descriptions were self‐centred and binary. Personal stories recounted by preceptors encouraged students and helped them understand that physicians are human and that failure is inevitable. Students felt relatively protected from failures that could impact patients. Both witnessing and participating in a failure event were distressing and sometimes at odds with their expectations. Students expressed a desire to talk about the experience. Conclusions: Medical students described examples of experiencing failure during medical school that transported them from the more certain black and white beginnings of their classroom into the uncertain shades of grey of clinical medicine. What the participants heard, saw and experienced suggests opportunities for classroom teachers to better prepare pre‐clinical students for the inevitability of failure in clinical medicine and opportunities for clinical teachers to engage in open, inclusive conversations surrounding failures that occur on their watch. From black and white to shades of grey, Shepherd et al. explore how students' perspectives on failure and uncertainty shift with the transition to clinical training. [ABSTRACT FROM AUTHOR]

The authors comment on the research paper "Novice Students Navigating the Clinical Environment in an Early Medical Clerkship" by J. Barrett et al. They discuss the role of novice medical students clerking patients in the clinical environment in Great Britain. They acknowledge these students for their time interacting with patients and exploring their ideas, concerns and expectations.

Context: Good judgement and the ability to make complex decisions are key attributes of a skilled professional. There has been limited study of doctors and their decision making, particularly in relation to making complex decisions. The study aims were to understand how trainee doctors develop practical wisdom through investigating their approach to difficult decision making, understanding the influences on the development of practical wisdom, and identifying potential interventions that may help develop this further. Methods: Constructing an understanding of the process of developing practical wisdom was analysed within a social constructivist frame. The study investigated trainee doctors at different stages of their careers. Qualitative semi‐structured interviews were used to explore the approaches doctors take to difficult decision making, as well as the key training influences in learning these skills. Constant comparative analysis was carried out within a grounded theory approach. Results: Key elements emerged from the data regarding the doctors themselves and the environments they worked in that assisted in developing decision making. This led to the construction of a conceptual model setting out the development of practical wisdom among trainee doctors. The model describes a process of gaining experience in decision making, moderated by key external and internal influences. The important roles of self‐efficacy and agency (relational) are highlighted as key enablers of the process. Discussion: The implications of this model are considered in relation to postgraduate training of doctors. The importance of training doctors to be self‐regulated learners in learning environments that support their development is highlighted. Aspects of the clinical learning environment (structure) such as rotation structures, the culture, supervision and feedback can all be enhanced. Self‐efficacy and relational agency, alongside other internal influences, are key factors in accelerating development of practical wisdom. Other studies have shown that these factors can be improved with targeted interventions. By exploring the development of practical wisdom among training doctors, Paes et al. describe how complex decision making is moderated by key internal and external influences such as self‐efficacy, agency and structure. [ABSTRACT FROM AUTHOR]

Objectives: There are only a few descriptive reports on the implementation of distributed medical education (DME) and these provide accounts of successful implementation from the senior leadership perspective. In Saskatchewan, over a period of 4 years (2010–2014), four family medicine residency sites were established and two additional sites could not be developed. The aim of this study was to identify challenges, success factors and pitfalls in DME implementation based upon experiences of multiple stakeholders with both successful and unsuccessful outcomes. Methods: Data were obtained through document analysis (n = 64, spanning 2009–2016; perspectives of government, senior leadership, management and learners), focus groups of management and operations personnel (n = 10) and interviews of senior leaders (n = 4). Challenges and success factors were ascertained through categorisation. Iterative coding guided by three sensitising frameworks was used to determine themes in organisational dynamics. Results: Both challenges and success factors included contextual variables, governance, inter‐ and intra‐organisational relationships (most common success factor), resources (most common challenge), the learning environment and pedagogy. Management and operations were only a challenge. Organisational themes affecting the outcome and the pitfalls included the pace of development across multiple sites, collaborative governance, continuity in senior leadership, operations alignment and reconciliation of competing goals. Conclusions: Emerging opportunities for DME can be leveraged through collaborative governance, aligned operations and resolution of competing goals, even in constrained contexts, to translate political will into success; however, there are pitfalls that need to be avoided. Our findings based upon multi‐stakeholder perspectives add to the body of knowledge on deployment, carefully considering the conditions for success and associated pitfalls. The authors share challenges and pitfalls that need to be navigated to successfully implement Distributed Medical Education by drawing on the concept of organizational dynamics [ABSTRACT FROM AUTHOR]

The article reports that professionalism lies at the heart of clinical practice and January 2005 issue of "Medical Education" is dedicated to papers exploring aspects of the educational processes involved in learning about being a good doctor. Medical students learn about professional practice by seeing others do it, by reflecting on what they see, and by shaping their own behaviour to mirror the models their senior colleagues portray. The processes involved, and the factors that contribute towards the construction of professional identity are largely unexplored areas in medical education.