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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. @MGottliebMD @TChanMD @fzaver @drellaway review the concepts of confidence, competence, and the intersectionality between the two in this 'State of the Science' paper on "Self" in medical education. [ABSTRACT FROM AUTHOR]

Introduction: Our very sense of self emerges through interactions with others. As part of this State of the Science series on Self, Society, and Situation, we introduce a qualitative ego network research approach. This research approach offers insights into the self's (the ego's) interpretation of and relation to named others in the social network in question. Purpose Visual mapping of participants' social networks is gaining traction, yet this research approach has received no focused attention in the health professions education (HPE) literature. A qualitative ego network approach is a compelling research approach because it uniquely maps participants' perceptions of the complex social world they are embedded in. Although many methodologies can explore participants' social world, ego networks can enhance expression of tacit knowledge of one's social environment and encourage reflection. This approach, combined with other qualitative data, can also reveal hidden relational data that the researcher may not observe or consider. To demonstrate its value as a visual methodology, we will showcase two examples of qualitative ego network studies. We then balance the paper with some critical reflections of this research approach. Conclusions: A qualitative ego network approach holds potential for deepening understanding of the self in relation to society and situation in future HPE research. We look forward to intentional, impactful and invigorated research using a qualitative ego network approach as we tackle unknowns about how self and society in specific HPE situations interact. Nimmon and Atherley introduce a qualitative ego network research approach that offers insights into how we interpret and relate to others in our social network. [ABSTRACT FROM AUTHOR]

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. By blending narrative and Indigenous research approaches, the authors explore Indigenous learners' motivations for pursuing a career in medicine, the barriers and enablers they encounter, and their future aspirations. [ABSTRACT FROM AUTHOR]

Context: Learning technologies are ubiquitous in medical schools, implemented in anticipation of more effective, active and authentic learning and teaching. Such thinking appears to be an instance of solutionism. The evidence is that academics' adoption of learning technologies is often limited in scale and scope and frequently fails to transform their teaching practices. Purpose: This paper aims to provide a contextualised analysis of considerations pertinent to the adoption of learning technologies by teaching staff. We contextualise a framework for understanding adoption of learning technologies in higher education by medical education. Conclusions: We identify multiple precursors that predict individual patterns of adoption, illuminating factors related to the technology, the individual staff member charged with adoption and the working environment. We offer conceptual clarity to the vexed issue of learning technology adoption and provide evidence explaining why, despite their widely promulgated potential, learning technologies do not offer an easy route to the transformation of medical education. If you build it will they learn? The authors explore why simply making learning technologies available does not optimize educational transformation. [ABSTRACT FROM AUTHOR]

Objectives: This paper stems from a desire to deepen our own understanding of why women might 'say no' when allies and sponsors offer or create opportunities for advancement, leadership or recognition. The resulting disparity between representation by men and women in leadership positions, invited keynote speakers and publication counts in academic medicine is a stubborn and wicked problem that requires a synthesis of knowledge across multidisciplinary literature. Acknowledging the complexity of this topic, we selected a narrative critical review methodology to explore reasons why one man's opportunity might be a woman's burden in academic medicine. Methods: We engaged with an iterative process of identifying, reviewing and interpreting literature from Psychology (cognitive, industrial and educational), Sociology, Health Professions Education and Business, placing no restrictions on context or year of publication. Knowledge synthesis and interpretation were guided by our combined expertise, lived experience, consultations with experts outside the author team and these guiding questions: (1) Why might women have less time for career advancement opportunities? (2) Why do women have less time for research and leadership? (3) How are these disparities maintained? Results: Turning down an opportunity may be a symptom of a much larger issue. The power of social expectations, culture and gender stereotypes remains a resistant force against calls for action. Consequently, women disproportionately take on other tasks that are not as well recognised. This disparity is maintained through social consequences for breaking with firmly entrenched stereotypes. Conclusions: Popular strategies like 'lean into opportunities', 'fake it till you make it' and 'overcome your imposter syndrome' suggest that women are standing in their own way. Critically, these axioms ignore powerful systemic barriers that shape these choices and opportunities. We offer strategies that allies, sponsors and peers can implement to offset the power of stereotypes. In this critical narrative review, the authors explore "reasons why one man's opportunity might be a woman's burden" in medical education to offer strategies that might help offset the power of stereotypes. [ABSTRACT FROM AUTHOR]

ObjectivesThe introduction of computerized testing offers several advantages for test administration, however, little research has examined students’ attitudes toward computerized testing. This paper, reports the attitudes of 202 students in a first year cell biology and histology course toward computerized testing and its influence on their study habits over a three year period. Design and methodsMultiple choice and image-based extra credit examinations and summative image-based examinations have been successfully administered in the course. The results indicate that students readily accept computer exams and that their study habits were influenced in a positive manner by the computer administered extra-credit examinations. ResultsOur results provide further evidence that medical students like the use of computer administered examinations and that the examinations may actually accentuate the learning experience. [ABSTRACT FROM AUTHOR]

Introduction: Students from low‐income backgrounds (LIB) have been under‐represented in Canadian medical schools for over fifty years. Despite our awareness of this problem, little is known about the experiences of aspiring physicians from LIB in Canada who are working towards medical school admission. Consequently, we have little insight into the barriers and facilitators that may be used to increase the representation of students from LIB in Canadian medical schools. Methods: This paper describes a qualitative description interview study aimed at understanding the experiences of aspiring physicians from LIB as they attempt to gain entry to medical school. We conducted semi‐structured interviews with 21 participants at different stages of their undergraduate, master's, and non‐medical professional education, and used the theories of intersectionality and identity capital as a theoretical framework for identifying barriers and facilitators to a career in medicine. Results: Participants experienced social, identity‐related, economic, structural and informational barriers to a career in medicine. Intrinsic facilitators included motivation, self‐confidence, attitude, strategy, information‐seeking and sorting, and financial literacy and increasing income. Extrinsic facilitators were social, informational, financial and institutional in nature. Conclusion: This study fills existing knowledge gaps in the literature by identifying the pre‐admissions barriers and facilitators encountered by aspiring physicians from LIB in Canada. The barriers and facilitators outlined in this study offer a framework for identifying target areas in developing support for admitting medical students from LIB. Given that medical students from LIB are more likely to serve underserved populations, our study is relevant to Canadian medical schools' social accountability commitment to producing physicians that meet the health needs of marginalised and vulnerable patients. Out of concern for socioeconomic diversity, the authors apply an intersectional approach to examine the barriers and facilitators faced by aspiring physicians from low‐income backgrounds. [ABSTRACT FROM AUTHOR]

Context Thirty years ago, it was suggested in the Edinburgh Declaration that medical school applicants should be selected not only on academic, but also on non-academic, attributes. The main rationale behind extending medical school selection procedures with the evaluation of (non-academic) personal qualities is that this will lead to the selection of students who will perform better as a doctor than those who are selected on the basis of academic measures only. A second rationale is the expectation that this will lead to a representative health workforce as a result of reduced adverse impact. The aims of this paper are (i) to describe what can be learned about the use of selection criteria other than grades from over 15 years of Dutch experience and (ii) to summarise current knowledge on the issue of adverse impact in relation to non-grades-based selection. Methods A narrative review was undertaken of the (published) evidence that has resulted from non-grades-based school-specific selection procedures in the Netherlands and from recent explorations of the effect of the use of non-grades-based selection criteria on student diversity. Results The Dutch evidence is grouped into five key themes: the effect of participation in voluntary selection procedures, the assessment of pre-university extracurricular activities, the use of work samples, Dutch experiences with situational judgement tests and the effects of changing circumstances. This is followed by several lessons learned for medical schools that aim to increase their student diversity. Conclusion Over the last 30 years, important steps towards reliable and valid methods for measuring non-academic abilities have been taken. The current paper describes several lessons that can be learned from the steps taken in the Dutch context. The importance of sharing evidence gathered around the globe and building on this evidence to reach our goal of predicting who will be a good doctor is acknowledged. [ABSTRACT FROM AUTHOR]

In this commentary, @ChrisWatling3 highlights new papers by Schrepel and by Cantillon to consider the often problematic influences of medicine's professional subcultures on clinical practice and education. [ABSTRACT FROM AUTHOR]

Objectives: In clinical reasoning, clinicians need to switch between automatic and effortful reasoning to solve both routine and non‐routine problems. This requires the ability to recognise when a problem is non‐routine and adapt one's reasoning mode accordingly, that is to 'slow down' the reasoning process. In the current study, we explored the process of these transitions between automatic and effortful reasoning by radiologists who performed ultrasound examinations during consultations at the polyclinic. Methods: Manifestations of slowing down in clinical reasoning were explored in 41 out‐patient consultations performed by five radiologists. Interviews before and after the consultations were combined with observations during the consultations to obtain proactively planned triggers, slowing down manifestations and situationally responsive initiators. Transcripts of the interviews and field notes of the observations were coded. The constant comparative method was used to classify slowing down manifestations. Results: In thirteen of the 41 consultations, slowing down moments were observed. Four manifestations of slowing down were identified: shifting, checking, searching and focusing. These manifestations mainly differed in how long radiologists maintained effortful reasoning, varying from very short periods (shifting and checking) to sustained periods (searching and focusing). Unexpected patient statements and ambiguous ultrasound images initiated the slowing down moments. Discussion: The results from this study contribute to understanding how clinicians transition from automatic to effortful reasoning. Also, this study revealed two sources of initiators of this transition in radiologists' consultations: statements made by the patient and conflicting or ambiguous visual information, in this case from ultrasound images. Natural variations in patient statements and visual information can be used as input of what might be meaningful variation in the domain of radiology education to support expertise development. In this paper, Groenier et al. demonstrate how radiologists transition from near‐automatic to effortful reasoning to illustrate how clinicians 'slow down' the reasoning process. [ABSTRACT FROM AUTHOR]

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

Context: Research suggests that feedback in the health professions is less useful than we would like. In this paper, we argue that feedback has become reliant on myths that perpetuate unproductive rituals. Feedback often resembles a discrete episode of an educator "telling," rather than an active and iterative involvement of the learner in a future‐facing process. With this orientation towards past events, it is not surprising that learners become defensive or disengaged when they are reminded of their deficits. Methods: We tackle three myths of feedback: (a) feedback needs praise‐criticism balancing rules; (b) feedback is a skill residing within the teacher; and (c) feedback is an input only. For each myth we provide a reframing with supporting examples from the literature. Conclusions: Equipping learners to engage in feedback processes may reduce the emotional burden on both parties, rendering techniques such as the feedback sandwich redundant. We also highlight the benefits for learners and teachers of conceptualising feedback as a relational activity, and of tracing the effects of information exchanges. These effects may be immediate or latent, and may manifest in different forms such as changes in learner evaluative judgement or professional identity. Well‐established feedback rules establish the importance of balancing praise and criticism and describe feedback as a skill residing within the teacher. Molloy et al. reframe feedback processes, arguing that involving the learner is the most productive way to create effects beyond the immediate task. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 357-365 Context Current debate in medical education focuses on the nature of 'competency-based medical education' (CBME) and whether or not it should be adopted. Many medical schools claim to run 'competency-based' curricula, but the structure of their programmes can differ radically. A review of the existing CBME literature reveals that little attention has been paid to defining the concept of competence. A straightforward examination of what is meant by the term 'competence' is noticeably missing from the literature, despite its impact on medical training. Objectives This paper aims to illustrate the varying conceptions of 'competence' by comparing and contrasting definitions provided in the health sciences education literature and discussing their respective impacts on medical education. Methods A systematic review of recent publications in medical education journals published in English and French was conducted to extract definitions of competence or, if definitions were not explicitly stated, to derive the authors' implicit conception of competence. A sample of 14 definitions from articles in the health sciences education field was studied using thematic analysis. Results There is agreement that competence is composed of knowledge, skills and other components. Although agreement about the nature of these other components is lacking, attitudes and values are suggested to be essential ingredients of competence. Furthermore, a clear divergence in conceptions of how a competent person utilises these components is apparent. One view specifies that competence involves selecting components according to specific situations, as required. A second view places greater emphasis on the synergy that results from the use of a combination of components in a given situation. Conclusions These conceptual distinctions have many implications for the way CBME is implemented. A conception of competence as the selection of components may lead to a greater emphasis, in a training setting, on the mastery of each component separately. A conception of competence as the use of a combination of components leads to greater emphasis on the synergy that results as they are deployed in clinical situations. [ABSTRACT FROM AUTHOR]

Context Narrative research, an inclusive term for a range of methodologies, has rapidly become part of medical education scholarship. Concepts In this paper we identify narrative inquiry as a particular theoretical and methodological framework within narrative research and outline its characteristics. We briefly summarise how narrative research has been used in studying medical learners' identity making in medical education. Uses of narrative inquiry We then turn to the uses of narrative inquiry in studying medical learners' professional identity making. With the turn to narrative inquiry, the shift is to thinking with stories instead of about stories. Conclusions We highlight four challenges in engaging in narrative inquiry in medical education and point toward promising future research and practice possibilities. [ABSTRACT FROM AUTHOR]

As a break from the usual lecture or case discussion to teach medical ethics, this paper reports on the utilization of attitudinal surveys in ethical areas where students face a choice of behaviours. The technique can stimulate students to better understand their own attitudes and hopefully motivate them to overcome resistance to more ethical but perhaps less desirable behaviours. However, the technique also serves as the basis for empirical ethical research. The first section of the paper provides background on the conceptualization of attitudes, their measurement, and the statistical techniques for their analysis. In the second section, the special characteristics of medical students as a study population and ethical considerations in surveying them are discussed. Thirdly, the author uses his work in researching and in teaching about students' willingness to treat patients infected with HIV as an example of survey and analytical techniques. Finally, methods for using surveys in the classroom are presented. [ABSTRACT FROM AUTHOR]

Context There exists a disparity between the views of physicians and the views of their patients on end-of-life decisions. However, the timing of when the end-of-life preferences of physicians and non-medically-trained individuals diverge is currently unknown. The objective of this paper is to characterise how preferences for medical interventions change throughout medical education and residency or fellowship training when confronted with scenarios of critical or terminal illness. Methods This is a single-centre cross-sectional study that enrolled medical students at Sidney Kimmel Medical College and residents and fellows at Thomas Jefferson University Hospital. Through an online survey we determined the preferences of medical trainees for specific interventions throughout medical training when presented with different clinical scenarios. Interventions were organised into three categories: standard, intermediate and aggressive. We analysed responses to questions regarding different scenarios in separate repeated measures logistic regression models. The probability of declining medical interventions was modelled, and significant predictors of refusal of interventions were identified. Results Years of training was a significant predictor of declining interventions for several scenarios. When faced with permanent physical disability, increased years of training led to a higher rate of refusal of intermediate ( OR = 1.14 [1.02-1.28], p = 0.02) and aggressive interventions ( OR = 1.15 [1.03-1.28], p = 0.01). For the scenario of terminal illness with associated physical disability, years of training significantly influenced refusal of intermediate ( OR = 1.14 [1.04-1.26], p = 0.006) and aggressive ( OR = 1.20 [1.08-1.34], p = 0.001) interventions. For the scenario of permanent cognitive impairment, increased years of training led to a higher rate of refusal of standard ( OR = 1.14 [1.01-1.29], p = 0.03), intermediate ( OR = 1.30 [1.13-1.50], p < 0.001) and aggressive ( OR = 1.38 [1.14-1.66], p = 0.001) interventions. Conclusion Changes in end-of-life preferences occur throughout medical training. Years of training influenced the likelihood of declining medical interventions when faced with scenarios of terminal illness and physical or cognitive disability. [ABSTRACT FROM AUTHOR]

Context This paper describes the transition processes experienced by Year 3 medical students during their longitudinal integrated clerkship ( LIC). The authors conceptualise the stages that encompass the transition through a LIC. Objectives The purpose of this study was to understand the perspectives of 12 Northern Ontario School of Medicine ( NOSM) Year 3 medical students about their transition process. Methods Data were collected longitudinally through three conversational interviews with each of these students, occurring before, during and after the clerkship. The authors used a guided walk methodology to explore students' everyday lives and elicit insights about the transition process, prompted by the locations and clinical settings in which the clerkship occurred. Results Participants identified three interconnected stages in the transition process: (i) shifting from classroom to clinical learning; (ii) dealing with disorientation and restoring balance, and (iii) seeing oneself as a physician. Interview data provided evidence for the adaptive strategies the participants developed in response to these stages. Conclusions Based on these findings, the transition process during a LIC can be characterised as one of entering the unfamiliar, with few forewarnings about the changes, of experiencing moments of confusion and burnout, and of eventual gains in confidence and competence in the clinical roles of a physician. Recommendations are made regarding future research opportunities to further scholarship on transitions. [ABSTRACT FROM AUTHOR]

ContextThe homeless are a significant group within society, which is increasing in size. They have demonstrably greater physical and mental health needs than the housed, and yet often have difficulty accessing primary health care. Medical ‘reluctance’ to look after homeless people is increasingly suggested as part of the problem. Medical education may have a role in ameliorating this. ObjectivesThis paper reports on the development and validation of a questionnaire specifically developed to measure medical students’ attitudes towards the homeless. Method and resultsThe Attitudes Towards the Homeless Questionnaire, developed using the views of over 370 medical students, was shown to have a Pearson test–retest reliability correlation coefficient of 0·8 and a Cronbach’s alpha coefficient of 0·74. ConclusionsThe Attitudes Towards the Homeless Questionnaire appears to be a valid and reliable instrument, which can measure students’ attitudes towards the homeless. It could be a useful tool in assessing the effectiveness of educational interventions. [ABSTRACT FROM AUTHOR]

Context Despite a growing and influential literature, 'professionalism' remains conceptually unclear. A recent review identified three discourses of professionalism in the literature: the individual; the interpersonal, and the societal-institutional. Although all have credibility and empirical support, there are tensions among them. Objectives This paper considers how these discourses reflect the views of professionalism as they are expressed by students and educator-practitioners in three health care professions, and their implications for education. Methods Twenty focus groups were carried out with 112 participants, comprising trainee and educator paramedics, occupational therapists and podiatrists. The focus group discussions addressed participants' definitions of professionalism, the sources of their perceptions, examples of professional and unprofessional behaviour, and the point at which participants felt one became 'a professional'. Results Analysis found views of professionalism were complex, and varied within and between the professional groups. Participants' descriptions of professionalism related to the three discourses. Individual references were to beliefs or fundamental values formed early in life, and to professional identity, with professionalism as an aspect of the self. Interpersonal references indicated the definition of 'professional' behaviour is dependent on contextual factors, with the meta-skill of selecting an appropriate approach being fundamental. Societal-institutional references related to societal expectations, to organisational cultures (including management support), and to local work-group norms. These different views overlapped and combined in different ways, creating a complex picture of professionalism as something highly individual, but constrained or enabled by context. Professionalism is grown, not made. Conclusions The conceptual complexity identified in the findings suggests that the use of 'professionalism' as a descriptor, despite its vernacular accessibility, may be problematic in educational applications in which greater precision is necessary. It may be better to assume that 'professionalism' as a discrete construct does not exist per se, and to focus instead on specific skills, including the ability to identify appropriate behaviour, and the organisational requirements necessary to support those skills. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 1152-1160 Context Power and leadership are concepts that are linked. Both are studied too infrequently in medical and health care settings, given the responsibilities and opportunities doctors and other health care personnel have to exert leadership and power appropriately to foster patient-centred and health care organisational goals. Methods This paper reviews Raven's concept of power, clarifies the bases of power that are available to doctors in different roles and provides illustrations of the application of the bases of power in medical practice. The relationship between power and leadership is explored, with an emphasis on how power and leadership are linked through the personal characteristics and competencies of the leader. Results Transformational leadership illustrates the incorporation and elaboration of power strategies into a principles-driven, relationship-oriented and empirically grounded form of leadership. Illustrations of the appropriate and inappropriate use of power and leadership in health care settings are provided. Conclusions The study of power, the study of leadership and their linkage should be incorporated to a greater degree into medical education at all levels. Strategies to achieve this end are suggested. [ABSTRACT FROM AUTHOR]

Medical Education 2011: 45: 1251-1261 Objectives Professional status and working arrangements can inhibit doctors from acknowledging and seeking care for their own ill health. Research identifies that a culture of immunity to illness within the medical profession takes root during training. What happens when trainee doctors become unwell during their formative period of education and training? What support do they receive and how do they perceive that the experience of ill health affects their training trajectory? These research questions were developed by a multidisciplinary team of researchers and health professionals, who adopted a qualitative approach to investigate the experiences of personal illness among trainees in their Foundation Programme (FP) years. Methods Semi-structured interviews were conducted with eight FP trainees from the Severn Deanery in southwest England who had experienced significant illness. Interpretative phenomenological analysis was used to conduct and analyse the interviews, resulting in a comprehensive list of master themes. This paper reports an interpretative analysis of the themes of Support, Illness Experience, Crossing the Line, Medical Culture, Stigma and Disclosure. Results Ineffective communication within the medical education and employment system underpins many of the difficulties encountered by trainees who are unwell. Coping style plays a key role in predicting how trainees experience support during and after their illness, although this may be influenced by their particular diagnoses. The barriers to disclosure of their illnesses are discussed within the context of mobilising and maintaining support. Concern about the impact of missing training as a result of ill health appears to be significant in the transmitting of an ethos of invulnerability within the medical culture. Conclusions Suggestions to improve support procedures for trainees who are unwell include the provision of greater flexibility within the rotation system along with independent pastoral support. Promoting the importance of disclosing significant illness as early as possible might go some way towards challenging the culture of invulnerability to illness that prevails among doctors. [ABSTRACT FROM AUTHOR]

Ng et al. argue that the antidote to solution‐ism may be epistemic reflexivity and its emphasis on personal and emancipatory knowledge. [ABSTRACT FROM AUTHOR]

Feedback on presentation skills is important for developing skilled educators, but often this feedback is based on evaluation tools that have been developed with little concern for psychometric issues or for how the information will be used for feedback. The purpose of this study was to develop a reliable participant questionnaire to assess the quality of continuing medical education (CME) presentations and to provide presenters with feedback.The questionnaire was developed using an iterative approach, with doctors as raters, and tested during a variety of CME presentations. The resulting questionnaire consists of 9 items rated on a 7-point Likert scale. The psychometric analysis reported in this paper was completed using data from grand rounds presentations.Psychometric analysis, based on 319 evaluations from 17 presentations (average of 19 evaluations/presentation), revealed a high level of reliability (0.91), indicating that the items met a reasonable standard and that the raters were discriminating between the quality of the presentations adequately.This 9-item, participant questionnaire provides a reliable measure of the quality of CME presentations, while also providing presenters with useful feedback. Further studies will investigate if this instrument can be used to assess other CME formats and how best to provide feedback to presenters. [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. [ABSTRACT FROM AUTHOR]

Context: There is a growing focus on the social missions of medical schools as a way of expressing an institutional commitment to service, responsibility and accountability. However, there has been little exploration of how a social mission translates to student experiences. Methods: This multicentre study explored how the social missions of eight medical schools (from Australia, Belgium, Canada, the Philippines, South Africa, Sudan and the USA) translated to their medical education programmes, and how their students perceived the mission. The study used a nested case study design involving interviews with final‐year medical students. Constructivist grounded theory techniques were used to analyse the data. Cultural‐historical activity theory concepts of externalisation and internalisation were used to structure the analyses. Results: The study identified substantial variation in the form, focus and depth of expression of each school's social mission, significant variation in how and to what extent the mission was externalised in the design of each school's undergraduate medical education programme, and significant variation in how students perceived the social mission and its translation to their training experiences. The translation of a social mission to educational outcomes depended on a cascade of externalisation and internalisation processes, each of which could alter or reinterpret the mission. Translation depended to a great extent on sensitising learners to the mission's values and issues and subsequently activating this knowledge in the context of direct clinical encounters that embodied the issues the mission was seeking to address. Conclusion: Whether a medical school's social mission is focused on equity of access to the medical profession or on its graduates serving particular community needs, the mission principles need to be translated into practice. This translation process involves a series of externalisation and internalisation steps, each of which determines how much and what aspects of the mission are translated. [ABSTRACT FROM AUTHOR]

Introduction: Impaired wellness among junior doctors is a significant problem. Connectedness and sense of belonging may be important factors to prevent and reduce mental ill‐health. Shared social spaces in which health care staff can meet informally are thought to improve connectedness; however, these spaces are in decline. It is unclear what is known about such spaces, how they are used, and their impact on wellness and learning. This study aims to identify and synthetise available literature that informs our current understanding of the nature of shared social spaces as an intervention impacting wellness and learning of junior doctors. Methods: A scoping review was conducted following the Arksey and O'Malley five‐step framework. The review question is 'What is the evidence of the impact of shared social spaces on wellness and learning of junior doctors?' We searched five databases: MEDLINE, EMBASE, APA PsychINFO, APA PsychExtra, and ERIC. We conducted thorough supplementary searches in addition to the database search. Results: We included 41 articles. These were predominantly letters, commentaries, and editorials with only five primary research studies. We identified four significant common attributes of shared social spaces, which can be credited with positive impacts on wellness and learning: (1) Informal: fostering connectedness and belonging, trust and teamwork and offering access to informal help and support; (2) safe: allowing reflection, debrief and raising of concerns; (3) functional: there is planning of clinical care activity, sense of control and engagement from users and provision of refreshment; (4) legitimate: regular maintenance and use of shared social spaces affect role modelling, sustainability and wellness culture. Discussion: This review identified several ways in which shared social spaces impact positively on learning and wellness. There is little primary research in this area. Future research would be useful to further examine how and why this works. This review identified several ways in which shared social spaces may impact positively on the wellness and learning of junior doctors. Future realist research would be useful to further examine how and why this works. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 143-152 Context The clinical workplace in which doctors learn involves many social groups, including representatives of different professions, clinical specialties and workplace teams. This paper suggests that medical education research does not currently take full account of the effects of group membership, and describes a theoretical approach from social psychology, the social identity approach, which allows those effects to be explored. Methods The social identity approach has a long history in social psychology and provides an integrated account of group processes, from the adoption of group identity through a process of self-categorisation, to the biases and conflicts between groups. This paper outlines key elements of this theoretical approach and illustrates their relevance to medical education. Results The relevance of the social identity approach is illustrated with reference to a number of areas of medical education. The paper shows how research questions in medical education may be usefully reframed in terms of social identity in ways that allow a deeper exploration of the psychological processes involved. Professional identity and professionalism may be viewed in terms of self-categorisation rather than simply attainment; the salience of different identities may be considered as influences on teamwork and interprofessional learning, and issues in communication and assessment may be considered in terms of intergroup biases. Conclusions Social identity theory provides a powerful framework with which to consider many areas of medical education. It allows disparate influences on, and consequences of, group membership to be considered as part of an integrated system, and allows assumptions, such as about the nature of professional identity and interprofessional tensions, to be made explicit in the design of research studies. This power to question assumptions and develop deeper and more meaningful research questions may be increasingly relevant as the nature and role of the medical profession change. [ABSTRACT FROM AUTHOR]

Farrell details the importance of coaches developing a shared conceptualization of identity and willingingness to cede control of discussion to allow for the emergence of creative and open conversations with coachees. [ABSTRACT FROM AUTHOR]

Seeing links others have missed? Our Editor‐in‐chief offers a challenge to health professional education scholars to draw Connections between Medical Education articles that offer new insights for the field. [ABSTRACT FROM AUTHOR]

Context Medical educators are increasingly paying attention to how bias creates inequities that affect learners across the medical education continuum. Such bias arises from learners' social identities. However, studies examining bias and social identities in medical education tend to focus on one identity at a time, even though multiple identities often interact to shape individuals' experiences. Methods: This article examines prior studies on bias and social identity in medical education, focusing on three social identities that commonly elicit bias: race, gender and profession. By applying the lens of intersectionality, we aimed to generate new insights into intergroup relations and identify strategies that may be employed to mitigate bias and inequities across all social identities. Results: Although different social identities can be more or less salient at different stages of medical training, they intersect and impact learners' experiences. Bias towards racial and gender identities affect learners' ability to reach different stages of medical education and influence the specialties they train in. Bias also makes it difficult for learners to develop their professional identities as they are not perceived as legitimate members of their professional groups, which influences interprofessional relations. To mitigate bias across all identities, three main sets of strategies can be adopted. These strategies include equipping individuals with skills to reflect upon their own and others' social identities; fostering in‐group cohesion in ways that recognise intersecting social identities and challenges stereotypes through mentorship; and addressing intergroup boundaries through promotion of allyship, team reflexivity and conflict management. Conclusions: Examining how different social identities intersect and lead to bias and inequities in medical education provides insights into ways to address these problems. This article proposes a vision for how existing strategies to mitigate bias towards different social identities may be combined to embrace intersectionality and develop equitable learning environments for all. The authors share a vision for addressing bias and inequities in medical education by embracing the intersection of multiple social identities. [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]

Aim Higher degrees have been proposed as one means whereby general practitioners can continue their professional development and avoid a slow decline into professional isolation and burnout. The United Medical and Dental School of Guy's and St Thomas' Hospitals' MSc in general practice has been available to experienced general practitioners for over a decade. This study reports some of the outcomes of participation for the 76 graduates of the first nine cohorts. Method As part of an ongoing programme of evaluation the graduates were sent a questionnaire which, in addition to seeking information about attainment of intended outcomes, gave respondents the opportunity to write freely about the contribution made by the course to their own professional and personal development. Seventy-one graduates completed the questionnaire, a response rate of 93%. Results and conclusions An increased confidence that arises not only from a broadened knowledge base and increased skills but also from a sense of having been enabled to explore more deeply into their discipline, is the most frequently and highly valued outcome of participation. Graduates appreciated having additional protected time and demonstrated an ability to use it productively. A further significant outcome was the ability of the course to confront those habitual assumptions of doctors which inform their practice in a manner that was both challenging and supportive. Tendencies to professional isolation and burnout appear to have been reversed with a greater sense of connectedness to their discipline. Doctors seeking to diversify their general practice careers beyond the task of providing medical services have found the MSc an important route for change. [ABSTRACT FROM AUTHOR]

Introduction: Dyad learning occurs when two students work together to acquire new skills and knowledge. Several studies have provided evidence to support the educational rationale for dyad learning in the controlled simulated setting. However, the role of dyad learning in the clinical setting remains uncertain. Unlike the simulated setting, learning in the clinical setting depends on a complex interplay between medical students, doctors, nurses and patients potentially making dyad learning less valuable in clerkships. The objective of this study was to explore how key stakeholders perceive the value of implementing dyad learning during medical students' clinical clerkships. Methods: In a constructivist qualitative study, we conducted 51 semi‐structured interviews with 36 key stakeholders involved in dyad learning, including 10 medical students, 12 doctors, five nurses and nine patients. Data were coded inductively using thematic analysis, then coded deductively using stakeholder theory as a theoretical framework. Results: We found that stakeholders generally perceived the educational impact of dyad learning in the clinical setting similarly but disagreed on its value. Students emphasised that dyad learning made them participate more actively during patient encounters and patients did not mind having two students present. Doctors and nurses considered dyad learning disruptive to the balance between service and training and reported that it did not resonate with their perception of good patient care. Conclusion: Dyad learning enables students to be more active during their clinical clerkships, but it easily disrupts the balance between service and training. This disruption may be exacerbated by the shifted balance in priorities and values between different stakeholder groups, as well as by making implicit teaching obligations more explicit for supervising doctors and nurses. Consequently, implementing dyad learning may not be perceived as valuable by doctors and nurses in the clinical setting, regardless of its pedagogical rationale. The authors demonstrate that collaborative learning between pairs of medical students is perceived and valued differently by different stakeholders in the clinical setting, particularly with respect to tge patient perspective. [ABSTRACT FROM AUTHOR]

Introduction: Capitalising on direct workplace observations of residents by interprofessional team members might be an effective strategy to promote formative feedback in postgraduate medical education. To better understand how interprofessional feedback is conceived, delivered, received and used, we explored both feedback provider and receiver perceptions of workplace feedback. Methods: We conducted 17 individual interviews with residents and eight focus groups with health professionals (HPs) (two nurses, two rehabilitation therapists, two pharmacists and two social workers), for a total of 61 participants. Using a constructivist grounded theory approach, data collection and analysis proceeded as an iterative process using constant comparison to identify and explore themes. Results: Conceptualisations and content of feedback were dependent on whether the resident was perceived as a learner or a peer within the interprofessional relationship. Residents relied on interprofessional role understanding to determine how physician competencies align with HP roles. The perceived alignment was unique to each profession and influenced feedback credibility judgements. Residents prioritised feedback from physicians or within the Medical Expertise domain—a role that HPs felt was over‐valued. Despite ideal opportunities for direct observation, operational enactment of feedback was influenced by power differentials between the professions. Discussion: Our results illuminate HPs' conceptualisation of feedback for residents and the social constructs influencing how their feedback is disseminated. Professional identity and social categorisation added complexity to feedback acceptance and incorporation. To ensure that interprofessional feedback can achieve desired outcomes, education programmes should implement strategies to help mitigate intergroup bias and power imbalance. Miles et al reveal how interprofessional feedback to residents creates a complex social process that requires education programs to implement strategies that address intergroup bias and power imbalance. [ABSTRACT FROM AUTHOR]

Medical educators from the Faculty of Medicine at the University of Adelaide, South Australia, have expressed reservations about the adequacy of some undergraduate medical students' English language proficiency for satisfactory academic and clinical performance. This study explores the occurrence and nature of the comments made in writing by clinical teachers about the English language proficiency of 568 students over a period of 4 years. The frequency and nature of the comments made by clinicians have important implications for the planning and implementation of pedagogical strategies to support non-English-speaking background medical students experiencing difficulties with their course due to language. Although the University of Adelaide has introduced initiatives in response to some of the problems that have been identified, it is recommended that any teaching interventions require careful evaluation through a longitudinal research design to ensure that their aims are being achieved. [ABSTRACT FROM AUTHOR]

Introduction: Medical education is moving to conceptualise feedback as a bidirectional learning conversation. Within this conversation, learners experience a tension between assessment and feedback. That perceived tension affects learners' outward performances. In this study, we aimed to characterise residents' experiences with this tension and its effect on learner authenticity within feedback conversations. Methods: In this constructivist grounded theory study, the authors were informed by Goffman's theory of impression management. During data analysis, Dweck's theory of mindset was adopted. The authors conducted semi‐structured interviews with 15 internal medicine residents. Data collection and analysis were conducted iteratively, using constant comparison to identify themes coinciding with impression management and mindset, ultimately developing a theoretical model to help explain residents' responses to tensions within feedback conversations. Results: Residents constantly felt 'scrutinized', and this affected their engagement in feedback conversations. They staged a performance within those conversations, linked to their underlying mindset: growth or fixed. Growth mindset was characterised by a focus on development as a physician and was associated with asking questions and seeking opportunities for growth. Fixed mindset was characterised by a focus on achieving a favourable evaluation and was associated with a hesitation to ask questions when faced with uncertainty and admit opportunities for growth, because they were concerned about impression management. Context influenced mindset and impression management. Residents adopted a fixed mindset and managed impressions when they perceived the permanence or consequences of evaluations within feedback. Residents adopted a growth mindset when they trusted the supervisor. Discussion: Residents assess the context of feedback conversations, altering the authenticity of their behaviours. Context, including the perceptions of formal assessment and relationships with supervisors, affected residents' mindset and impression management. Providing space for relationship‐building and clarifying the purpose and structure of assessment may be helpful in supporting effective learning conversations in graduate medical education. Caught between learning and performance mindsets, Huffman et al. reveal that residents "front stage" a performance based mindset based on perceptions of formal assessment and their relationship with supervisors. [ABSTRACT FROM AUTHOR]

Objectives: Cognitive load theory (CLT) focuses on the limited bandwidth of working memory. Core to CLT is the concept of cognitive overload, which occurs when working memory demands exceed working memory capacity, and learning and performance suffer. Within health professions education (HPE), workplace learning settings are very complex, placing learners at high risk of cognitive overload. Although continuous monitoring of physiologic parameters can indicate states of high cognitive load, how to practically identify cognitively overloaded learners within everyday workplace settings is not well understood. We sought to characterise how attending physicians described their perceiving of cognitive overload among learners in two different workplace settings: the gastrointestinal endoscopy suite and the intensive care unit. Methods: We performed a secondary qualitative analysis of transcripts of interviews with workplace teachers that had been carried out during two previous studies. These studies had addressed different objectives but both were informed by CLT. Each included questions that prompted participants to reflect on how they perceived cognitive overload to manifest among learners in the workplace. To investigate the phenomenon of cognitive overload, we developed a new codebook and performed content analysis. Results: We analysed 42 interview transcripts (22 endoscopists, 12 hospitalists, eight intensivists). Participants described four behaviours they had witnessed among learners they thought were cognitively overloaded: poor performance on workplace tasks; non‐verbal physical manifestations (including posture, eye and body movements and autonomic functions); verbal utterances (words and sounds), and interpersonal interactions with team members. Endoscopists often described individually oriented examples, whereas intensivists and hospitalists tended to frame examples within an interpersonal context. Conclusions: We identified four overarching ways in which HPE workplace teachers perceived learners as appearing to be cognitively overloaded. Workplace teachers and learners should be mindful of and watch for these signs, which may signal states of cognitive overload. Earlier recognition of cognitive overload may facilitate timely action to reduce cognitive overload and promote learning. To help educators identify cognitively overloaded trainees, Sewell et al. characterize four different indicators of overload that manifest in the HPE workplace. [ABSTRACT FROM AUTHOR]

It is hard to reconcile the fresh faced idealism and altruistic aspirations of candidates at interview for medical school, or the optimism shown by junior medical students in their early discussions about the role of the doctor, with the scepticism and apparent detachment of at least some of the world weary graduates who stagger off the end of the production line. Instruments that measure empathic response from the patient's perspective, such as the Consultation and Relational Empathy Measure developed by two researchers could play a valuable role in both research and assessment.

Context: Critical reflection may improve health professionals' performance of the social roles of care (eg collaboration) in indeterminate zones of practice that are ambiguous, unique, unstable or value‐conflicted. Research must explore critical reflection in practice and how it is developed. In this study, we explored what critical reflection consisted of in a context known for indeterminacy, and to what sources participants attributed their critically reflective insights and approaches. Methods: The study context was the interface between health care and education for children with chronic conditions or disabilities necessitating health‐related recommendations and supports (eg accommodations or equipment) at school. We conducted a secondary analysis of 42 interview transcripts from an institutional ethnographic study involving health professionals, school‐based educators and parents of children with chronic conditions or disabilities. We coded all transcripts for instances of critical reflection, moments that seemed to lack but could benefit from critical reflection, and participant‐attributed sources of critically reflective insights. Results: Critically reflective practice involved getting to know the other, valuing and leveraging different forms and sources of knowledge, identifying and communicating workarounds (ie strategies to circumvent imperfect systems), seeing inequities, and advocating as collaborators, not adversaries. Participants invariably attributed critically reflective insights to personal experiences such as former careers or close personal relationships. Conclusions: This study shows that personal experiences and connections inspire critically reflective views, and that being critically reflective is not a binary trait possessed (or not) by individuals. It is learnable through personally meaningful experiences. Health professions education could aim to preserve philosophical space for personal experience as a source of learning and integrate evidence‐informed approaches to foster critically reflective practice. Ng et al. explore the implications of their observation that critical reflection improved social aspects of practice (advocacy and collaboration) when clinicians worked with schools to support children with disabilities, but that it did so opportunistically. [ABSTRACT FROM AUTHOR]

Context: A number of systematic reviews have evaluated the impacts of continuing professional development (CPD). These reviews, due to their focused nature, may fail to capture the full range of impacts of CPD. This scoping review aims to explore the broader impacts of CPD with the intention of developing a categorisation of the types of impact of CPD. Methods: The authors searched MEDLINE, CINAHL and ERIC databases for studies published between 2007 and 2017 that looked at the impacts of formal CPD programmes for all health professionals. Studies were independently screened for eligibility; one reviewer charted data for all included studies, a sample of 10% was reviewed by a second reviewer. The charted data were analysed using both qualitative and quantitative content analysis. Results: The search returned 2750 manuscripts; 192 manuscripts describing 191 studies were included in this review. Most articles were from the USA (78 studies, 41%) and included medical doctors in the population (105 studies, 55%). Twelve categories of impact were generated through conventional content analysis: knowledge, practice change, skill, confidence, attitudes, career development, networking, user outcomes, intention to change, organisational change, personal change and scholarly accomplishments. Knowledge was most commonly measured (103 studies, 54%), whereas measurement of scholarly accomplishments was the least common (10 studies, 5%). Conclusions: Existing evidence takes a narrow view when assessing the impacts of CPD. Emphasis on measuring impacts as knowledge, behaviour, confidence, skills and attitudes may be due to the widely accepted four levels of evaluation from the Kirkpatrick Model or because the majority of studies used quantitative methods. The categories proposed in this review may be used to capture a broader view of the impacts of CPD programmes, contributing to the evidence base for their value and translating into CPD programmes that truly transform health professionals, their careers and their practice. In an effort to allow better consideration of the wide range of impacts enabled by CPD programs, Allen et al. develop a categorisation model that can productively be used in future evaluations. [ABSTRACT FROM AUTHOR]

Context: Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio‐relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. Methods: Constructivist grounded theory informed data collection and analysis; during semi‐structured interviews, we used rich pictures to elicit team members' perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. Results: Routine care became complex when the prognosis was unknown, when treatment was either non‐existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants' training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. Conclusions: Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non‐physician team members in advocacy training. The authors demonstrate that navigating clinical complexity relies heavily on advocacy, and they discuss the challenges of both enacting and teaching this critical aspect of care. [ABSTRACT FROM AUTHOR]

Discusses the need to consider the needs and perceived role of medical students in an alternative form of medical education. Statistical analyses used by researchers which failed to factor in individual student's role and needs; New Path methods introduced as an alternative to traditional methods of learning.

Objectives Although trainees and trainers find feedback interactions beneficial, difficulties in giving and receiving feedback are reported. Few studies have explored what drives trainees to seek feedback. This study explores how workplace-based assessments ( WBAs) influence the ways surgical trainees seek feedback and feedback interactions. Methods Utilising a template analysis approach, we conducted 10 focus groups with 42 surgical trainees from four regions across the UK. Data were independently coded by three researchers, incorporating three a priori themes identified from a previous quantitative study. Further themes emerged from exploration of these data. The final template, agreed by the three researchers, was applied to all focus group transcripts. The themes were linked in a diagrammatical form to allow critical exploration of the data. Results Trainees' perceptions of the purpose of WBA for learning or an assessment of learning, and their relationship with their trainer impacted upon how trainees chose to use WBA. Perceiving WBA as a test led trainees to 'play the game': seek positive and avoid negative feedback through WBA. Perceiving WBA as a chance to learn led trainees to seek negative feedback. Some trainees sought negative feedback outside WBA. Negative feedback was more important for changing practice compared with positive feedback, which enabled trainees to 'look good' but had less of an effect on changing clinical practice. The timing of feedback relative to WBA was also important, with immediate feedback being more beneficial for learning; however, delayed feedback was still sought using WBA. Discussion Trainees' perceptions of the purpose of WBA and their relationship with their trainer informed when they chose to seek feedback. Trainees who perceived WBA as a test were led to 'play the game' by seeking positive and avoiding negative feedback. Outside of WBA, trainees sought negative feedback, which was most important for change in practice. [ABSTRACT FROM AUTHOR]

CONTEXT The erosion of empathy in medical students is well documented. Both the hidden curriculum associated with poor role modelling and a sense of burnout have been proposed as key factors, but the precise mechanisms by which this loss of empathy occurs have not been elaborated. OBJECTIVES In the context of a course designed to help students manage the hidden curriculum, we collected data that raised questions about current conceptualisations of the aspects of medical training that lead to loss of empathy. METHODS We held nine sessions in the first year of clinical clerkship, in which we asked students to bring to the group their experiences of the hidden curriculum for reflection. Course sessions were recorded, transcribed and qualitatively analysed, and themes were generated for further exploration. RESULTS We identified an identity developmental trajectory in early clerkship in which students started with feelings of excitement, transitioned quickly to 'shock and awe', progressed into 'survival mode' and then passed into a stage of 'recovery'. Interestingly, in the early stages, students' sense of empathic virtuosity was reinforced. It was not until later, when students were more comfortable in their clinical role, that they reported their tendency to connect with the patient only as an afterthought to the encounter, or not at all, and needed to remind themselves to care. CONCLUSIONS We offer new data for consideration with regard to medical students' loss of empathy during early clinical training that suggest it is the process of making patient care routine that shifts the patient from the status of an individual with suffering to the object of the work of being a physician. [ABSTRACT FROM AUTHOR]

Context Professional identity formation has become a key focus for medical education. Who one becomes as a physician is contingent upon learning to conceptualise who the other is as a patient, yet, at a time when influential ideologies such as patient-centred care have become espoused values, there has been little empirical investigation into assumptions of 'patient' that trainees take up as they progress through their training. Methods Our team employed a critical discourse analysis approach to transcripts originally produced from a micro-ethnography of medical student learning on an acute care in-patient paediatric ward. The dataset included 20 case presentations and 14 sign-over rounds taken from a 3-week observation period. We paid specific attention to how trainees used language to talk about, refer to and categorise patients. Results Identified discourses included patient-as-disease-category, patient-as-educational-commodity and patient-as-marginalised-actor. These discourses conceptualise 'patient' as an entity that is principally biomedical, useful for clinical learning and spoken for and about. Medical student participation in these discourses contributes to an identity that allows them to move further into the professional medical world they are joining. Conclusions We contend that as learners participate in these discourses, they are also performatively produced by them. By making these discourses visible, we can consider how to minimise unintended effects such discourses may cause. Our findings, although limited, offer a glimpse of the effects that those assumptions may have as we look to align better the formation of professional medical identity with the ideals of patient-centred care and socially responsible health care systems. [ABSTRACT FROM AUTHOR]

Context Medical schools increasingly value and focus on teaching students intercultural competency within present-day multicultural society. Little is known about the experiences of cultural minority students in intercultural competence activities. Objectives This article discusses the intercultural competence activities of medical education in a Dutch university from the perspective of cultural minority students. We will formulate recommendations for how to stimulate intercultural competency in, as well as inclusiveness of, medical education. Methods A qualitative evaluation was performed within a medical school in the Netherlands. Data were collected through interviews ( n = 23), a focus group (six participants) and participant observations (20 hours). Thematic analysis was performed. Results Cultural minority students experienced a lack of respect and understanding by cultural majority students and teachers. Education activities intended to transfer intercultural knowledge, address personal prejudice and stimulate intercultural sensitivity were perceived as stigmatising and as creating an unsafe climate for cultural minority students. Cultural minority and majority students on campus seemed segregated and the intercultural awareness of minority students was not integrated in intercultural competence activities. Conclusions As cultural minority students were confronted with microaggressions, the medical school did not succeed in creating a safe education environment for all students. Contrary to their aims and intentions, intercultural competence activities had limited effect and seemed to support the polarisation of cultural minority and majority students and teachers. This can be seen as pointing towards a hidden curriculum privileging majority over minority students. For structural integration of intercultural competency in medical education, the focus must penetrate beyond curricular activities towards the critical addressing of the culture and structure of medical school. Collective commitment to creating a safe and inclusive education climate is vital. This requires fostering social cohesion between minority and majority students and teachers, raising awareness and the practice by all involved of critical (self-)reflexivity on cultural prejudice and dominant, exclusionary norms in academic medicine. [ABSTRACT FROM AUTHOR]

Context Evidence strongly supports that direct observation is a valid and reliable assessment tool; support for its impact on learning is less compelling, and we know that some learners are ambivalent about being observed. However, learners' perceptions about the impact of direct observation on their learning and professional development remain underexplored. To promote learning, we need to understand what makes direct observation valuable for learners. Methods Informed by constructivist grounded theory, we interviewed 22 learners about their observation experiences. Data collection and analysis occurred iteratively; themes were identified using constant comparative analysis. Results Direct observation was widely endorsed as an important educational strategy, albeit one that created significant anxiety. Opaque expectations exacerbated participants' discomfort, and participants described that being observed felt like being assessed. Consequently, participants exchanged their 'usual' practice for a 'textbook' approach; alterations to performance generated uncertainty about their role, and raised questions about whether observers saw an authentic portrayal of their knowledge and skill. Conclusion An 'observer effect' may partly explain learners' ambivalence about direct observation; being observed seemed to magnify learners' role ambiguity, intensify their tensions around professional development and raise questions about the credibility of feedback. In turn, an observer effect may impact learners' receptivity to feedback and may explain, in part, learners' perceptions that useful feedback is scant. For direct observation to be valuable, educators must be explicit about expectations, and they must be aware that how learners perform in the presence of an observer may not reflect what they do as independent practitioners. To nurture learners' professional development, educators must create a culture of observation-based coaching that is divorced from assessment and is tailored to developing learners' identities as practitioners of both the art and the science of medicine. [ABSTRACT FROM AUTHOR]

Context High-income country (HIC) trainees are undertaking global health experiences in low- and middle-income country (LMIC) host communities in increasing numbers. Although the benefits for HIC trainees are well described, the benefits and drawbacks for LMIC host communities are not well captured. Objectives This study evaluated the perspectives of supervising physicians and local programme coordinators from LMIC host communities who engaged with HIC trainees in the context of the latter's short-term experiences in global health. Methods Thirty-five semi-structured interviews were conducted with LMIC host community collaborators with a US-based, non-profit global health education organisation. Interviews took place in La Paz, Bolivia and New Delhi, India. Interview transcripts were assessed for recurrent themes using thematic analysis. Results Benefits for hosts included improvements in job satisfaction, local prestige, global connectedness, local networks, leadership skills, resources and sense of efficacy within their communities. Host collaborators called for improvements in HIC trainee attitudes and behaviours, and asked that trainees not make promises they would not fulfil. Findings also provided evidence of a desire for parity between the opportunities afforded to US-based staff and those available to LMIC-based partners. Conclusions This study provides important insights into the perspectives of LMIC host community members in the context of short-term experiences in global health for HIC trainees. We hope to inform the behaviour of HIC trainees and institutions with regard to international partnerships and global health activities. [ABSTRACT FROM AUTHOR]

Context Intimate partner violence ( IPV) is a significant cause of morbidity and mortality in women worldwide. Numerous health organisations have called for increased education for health care practitioners who encounter IPV patients and the first clinical guidelines for health services responding to IPV were recently published. This renewed focus has created a need to examine the current evidence for IPV education so that it may inform the next generation of educational interventions. Objectives This study was designed to examine the effects of IPV educational interventions on the knowledge, attitudes, skills and behaviours of allied health care practitioners ( AHCPs). Methods We conducted a systematic search of multiple databases up to the end of May 2015. We selected studies that included IPV educational interventions for AHCPs and that measured knowledge, attitude, skill or behavioural outcomes. Studies were evaluated based on methodological quality, education context and outcome measurement. Results We found 2757 articles from which 18 were selected for inclusion. Study participants included nurses, dentists, social workers and paramedics. Educational interventions ranged widely in length, delivery format and topics covered. Findings indicate that improvements in some knowledge, attitudes, skills and behaviours are associated with education, although the lack of high-quality studies indicates that conclusions should be treated with caution. Conclusions Future studies should be conducted using rigorous methodology and validated instruments to measure evidence-based outcomes and should target a wider range of AHCPs. Recommendations are provided on education content and delivery, study methodology and outcome measurement based on insights gained from selected studies. [ABSTRACT FROM AUTHOR]

This commentary argues for the importance of informing patients about their participation in medical education when being cared for by trainees. [ABSTRACT FROM AUTHOR]