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Introduction Many health professions education (HPE) scholars frame assessment validity as a form of argumentation in which interpretations and uses of assessment scores must be supported by evidence. However, what are purported to be validity arguments are often merely clusters of evidence without a guiding framework to evaluate, prioritise, or debate their merits. Argumentation theory is a field of study dedicated to understanding the production, analysis, and evaluation of arguments (spoken or written). The aim of this study is to describe argumentation theory, articulating the unique insights it can offer to HPE assessment, and presenting how different argumentation orientations can help reconceptualize the nature of validity in generative ways. Methods The authors followed a five-step critical review process consisting of iterative cycles of focusing, searching, appraising, sampling, and analysing the argumentation theory literature. The authors generated and synthesised a corpus of manuscripts on argumentation orientations deemed to be most applicable to HPE. Results We selected two argumentation orientations that we considered particularly constructive for informing HPE assessment validity: New rhetoric and informal logic. In new rhetoric, the goal of argumentation is to persuade, with a focus on an audience's values and standards. Informal logic centres on identifying, structuring, and evaluating arguments in real-world settings, with a variety of normative standards used to evaluate argument validity. Discussion Both new rhetoric and informal logic provide philosophical, theoretical, or practical groundings that can advance HPE validity argumentation. New rhetoric's foregrounding of audience aligns with HPE's social imperative to be accountable to specific stakeholders such as the public and learners. Informal logic provides tools for identifying and structuring validity arguments for analysis and evaluation.

Uncertainty is an inevitable part of medical practice. An ability to tolerate uncertainty is viewed as a key competency across many health-care systems. Poor uncertainty tolerance (UT) has been linked to negative outcomes including reduced psychological well-being in medical students. A variety of medical education interventions have been developed with the intention of increasing medical students' UT. However, there is no synthesis of these studies available to inform education and research practice. Our aim was to conduct a scoping review of medical education interventions that evaluate their impact on UT.Medline, PsycInfo, Embase and ERIC databases were searched for articles published from inception to December 2020. An extensive supplementary search was conducted and both quantitative and qualitative evaluations were included. For each intervention, we categorised the stimulus of uncertainty (ambiguity, complexity and/or probability) and mapped the students' reported cognitive, behavioural, and/or emotional response(s) to uncertainty onto an existing conceptual framework.Twenty-two of 24 included studies reported a positive impact on medical student UT in at least one domain (cognitive, behavioural or emotional). Interventions included problem based learning-based curricula, medical humanities, simulation, reflection and assessment. We found in four studies that a negative response in the emotional domain was reported despite positive responses also being reported in the cognitive and/or behavioural domains.We identified a range of medical education interventions which report a positive impact on medical student UT. Further research is required to understand why a single intervention may stimulate a negative emotional response alongside a positive cognitive or behavioural response. In turn, this could support stakeholders such as policymakers and institutions to adapt the medical curriculum to better prepare their medical students for practice by enhancing their UT.

Fundamental challenges exist in researching complex changes of assessment practice from traditional objective-focused 'assessments of learning' towards programmatic 'assessment for learning'. The latter emphasise both the subjective and social in collective judgements of student progress. Our context was a purposively designed programmatic assessment system implemented in the first year of a new graduate entry curriculum. We applied critical realist perspectives to unpack the underlying causes (mechanisms) that explained student experiences of programmatic assessment, to optimise assessment practice for future iterations.Data came from 14 in-depth focus groups (N = 112/261 students). We applied a critical realist lens drawn from Bhasker's three domains of reality (the actual, empirical and real) and Archer's concept of structure and agency to understand the student experience of programmatic assessment. Analysis involved induction (pattern identification), abduction (theoretical interpretation) and retroduction (causal explanation).As a complex educational and social change, the assessment structures and culture systems within programmatic assessment provided conditions (constraints and enablements) and conditioning (acceptance or rejection of new 'non-traditional' assessment processes) for the actions of agents (students) to exercise their learning choices. The emergent underlying mechanism that most influenced students' experience of programmatic assessment was one of balancing the complex relationships between learner agency, assessment structures and the cultural system.Our study adds to debates on programmatic assessment by emphasising how the achievement of balance between learner agency, structure and culture suggests strategies to underpin sustained changes (elaboration) in assessment practice. These include; faculty and student learning development to promote collective reflexivity and agency, optimising assessment structures by enhancing integration of theory with practice, and changing learning culture by both enhancing existing and developing new social structures between faculty and the student body to gain acceptance and trust related to the new norms, beliefs and behaviours in assessing for and of learning.

War negatively impacts health professional education when health care is needed most. The aims of this scoping review are to describe the scope of barriers and targeted interventions to maintaining health professional education during war and summarise the research.We conducted a scoping review between 20 June 2018 and 2 August 2018. The search was restricted to English publications including peer-reviewed publications without date ranges involving war and health professional education (medical school, residency training and nursing school), with interventions described to maintain educational activities. Two independent reviewers completed inclusion determinations and data abstraction. Thematic coding was performed using an inductive approach allowing dominant themes to emerge. The frequency of barrier and intervention themes and illustrative quotes were extracted. Articles were divided into modern/postmodern categories to permit temporal and historical analysis of thematic differences.Screening identified 3271 articles, with 56 studies meeting inclusion criteria. Publication dates ranged from 1914-2018 with 17 unique wars involving 17 countries. The studies concerned medical students (61.4%), residents (28.6%) and nursing students (10%). Half involved the modern era and half the postmodern era. Thematic coding identified five categories of barriers and targeted interventions in maintaining health professions education during war: curriculum, personnel, wellness, resources, and oversight, with most involving curriculum and personnel. The distribution of themes among various health professional trainees was similar. The frequency and specifics changed temporally reflecting innovations in medical education and war, with increased focus on oversight and personnel during the modern era and greater emphasis on wellness, curriculum, and resources during the postmodern era.There are overarching categories of barriers and targeted interventions in maintaining health professional education during war which evolve over time. These may serve as a useful framework to strategically support future research and policy efforts.

There is a growing drive to improve the heterogeneity of medical school cohorts. However, those from lower socio-economic groups remain under-represented. Understanding the methods used by applicants to prepare for medical school selection, and the challenges they face with respect to opportunities and access, may provide important insights to this lack of diversity. This research considered the influence of socio-demographic background on preparation for medical school selection and on the successful offer of a place.All eligible applicants to a large UK medical school were invited to complete an anonymous online survey (international and mature applicants excluded), detailing demographic data and experiences of preparing for selection and challenges faced (n = 1885). Selection outcomes across all UK medical schools were examined for consenting students (n = 955). Univariate and multivariate analyses explored the associations of preparatory activities and demographic data with subsequent offer of a place at a UK medical school.The survey response rate was 66.4%. Clinical work experience (hospital or general practice), fee-based courses for admissions tests and school preparation courses for interview were activities significantly associated with the offer of a place (P .05). Those attending independent (private) schools most frequently reported school support and fee-based courses to support preparation (P .01). Applicants from state non-selective (SNS) schools and lower socio-economic groups more frequently reported challenges in accessing fee-based support, school interview courses and clinical work experience (P ≤ .02).Clinical work experience, commercial courses for admissions tests and school-based support for interview represent areas of preparation that are associated with success. However, they also represent areas that are more challenging to access for demographic groups traditionally under-represented in medicine. Addressing complex issues of fairness in highly selective higher education settings can appear an insurmountable task. These preparatory activities represent key areas for applicants, schools and institutions to explore and address.

BackgroundActive learning relies on students' engagement with teachers, study materials and/or each other. Although medical education has adopted active learning as a core component of medical training, teachers have difficulties recognising when and why their students engage or disengage and how to teach in ways that optimise engagement. With a better understanding of the dynamics of student engagement in small-group active learning settings, teachers could be facilitated in effectively engaging their students.MethodsWe conducted a video-stimulated recall study to explore medical students' engagement during small-group learning activities. We recorded one teaching session of two different groups and selected critical moments of apparent (dis)engagement. These moments served as prompts for the 15 individual semi-structured interviews we held. Interview data were analysed using Template Analysis style of thematic analysis. To guide the analysis, we used a framework that describes student engagement as a dynamic and multidimensional concept, consisting of behavioural, cognitive and emotional components.ResultsThe analysis uncovered three main findings: (1) In-class student engagement followed a spiral-like pattern. Once students were engaged or disengaged on one dimension, other dimensions were likely to follow suit. (2) Students' willingness to engage in class was decided before class, depending on their perception of a number of personal, social and educational antecedents of engagement. (3) Distinguishing engagement from disengagement appeared to be difficult for teachers, because the intention behind student behaviour was not always identifiable.DiscussionThis study adds to the literature by illuminating the dynamic process of student engagement and explaining the difficulty of recognising and influencing this process in practice. Based on the importance of discerning the intentions behind student behaviour, we advise teachers to use their observations of student (dis)engagement to initiate interaction with students with open and inviting prompts. This can help teachers to (re-)engage students in their classrooms.

Introduction While authorship plays a powerful role in the academy, research indicates many authors engage in questionable practices like honorary authorship. This suggests that authorship may be a contested space where individuals must exercise agency-a dynamic and emergent process, embedded in context-to negotiate potentially conflicting norms among published criteria, disciplines and informal practices. This study explores how authors narrate their own and others' agency in making authorship decisions. Method We conducted a mixed-methods analysis of 24 first authors' accounts of authorship decisions on a recent multi-author paper. Authors included 14 females and 10 males in health professions education (HPE) from U.S. and Canadian institutions (10 assistant, 6 associate and 8 full professors). Analysis took place in three phases: (1) linguistic analysis of grammatical structures shown to be associated with agency (coding for main clause subjects and verb types); (2) narrative analysis to create a 'moral' and 'title' for each account; and (3) dialectic integration of (1) and (2). Results Descriptive statistics suggested that female participants used we subjects and material verbs (of doing) more than men and that full professors used relational verbs (of being and having) more than assistant and associate. Three broad types of agency were narrated: distributed (n = 15 participants), focusing on how resources and work were spread across team members; individual (n = 6), focusing on the first author's action; and collaborative (n = 3), focusing on group actions. These three types of agency contained four subtypes, e.g. supported, contested, task-based and negotiated. Discussion This study highlights the complex and emergent nature of agency narrated by authors when making authorship decisions. Published criteria offer us starting point-the stated rules of the authorship game; this paper offers us a next step-the enacted and narrated approach to the game.

Multisource feedback (MSF), also called 360-degree assessment, is one form of assessment used in postgraduate training. However, there is an ongoing discussion on its value, because the factors that influence the impact of MSF and the main impact of MSF are not fully understood. In this study, we investigated both the influencing factors and the impact of MSF on residency training.We conducted a qualitative case study within the boundaries of the residency training for paediatricians and paediatric surgeons at a University Hospital. We collected data from seven focus group interviews with stakeholders of MSF (residents, raters and supervisors). By performing a reflexive thematic analysis, we extracted the influencing factors and the impact of MSF.We found seven influencing factors: MSF is facilitated by the announcement of a clear goal of MSF, the training of raters on the MSF instrument, a longitudinal approach of observation, timing not too early and not too late during the rotation, narrative comments as part of the ratings, the residents' self-assessment and a supervisor from the same department. We found three themes on the impact of MSF: MSF supports the professional development of residents, enhances interprofessional teamwork and increases the raters' commitment to the training of residents.This study illuminates the influencing factors and impact of MSF on residency training. We offer novel recommendations on the continuity of observation, the timing during rotations and the role of the supervisor. Moreover, by discussing our results through the lens of identity formation theory, this work advances our conceptual understanding of MSF. We propose identity formation theory as a framework for future research on MSF to leverage the potential of MSF in residency training.

Certain clinical pelvic examination (PE) teaching methods have been critiqued for prioritising student learning over patient autonomy and for not accurately representing diverse patient communities. As such, patient-centred and culturally competent approaches to the PE may need further emphasis in the medical curriculum-in particular, in content delivered to students before patient interaction. Classroom materials serve as students' first exposure to the sensitive procedure. This research explores how patients are represented in these materials.A situational analysis was conducted on 10 purposively sampled PE learning materials for the 2019/20 academic year from five undergraduate medical schools in Canada. Situational analysis focuses on analysing discourse but is epistemically aligned with post-structuralism (most notably Foucault's theories involving discursive power) and allows for specific consideration of 'silences' in the data. Collected data were analysed using cartographic approaches according to this methodology, with particular attention paid to the tenets and frameworks of patient-centred and culturally competent care.Overall, content in these materials misrepresented and under-represented patients. Materials contained both outdated and unnecessarily sexualised language, in addition to a lack of patient diversity. Clinical authority was often centred over patient agency, and several updated PE techniques known to improve patient experience were absent. Patient-centred and culturally competent approaches were therefore inadequately highlighted in most of the materials.Depictions contained in these materials may be perpetuating stereotypes and biases in medicine and may be working to maintain teaching practices that cause harm to patients (standardised and regular) who students interact with in both clinical and educational settings. Efforts may be needed to improve classroom materials on the PE so that they more adequately centre patients and provide opportunities to discuss culturally competent approaches to the procedure that (i) may not be covered in other parts of the PE curriculum and (ii) can reduce known health disparities.

Medical training during the COVID-19 pandemic has placed extra-ordinary demands on individuals within a context of rapid and iterative systems changes. The contemporaneous lived experience of trainees during this time has mainly been examined with surveys. Our study aims to provide a rich account of the experience of being a trainee during the pandemic to deepen our conceptual understanding of wellness. This holds relevance as we move away from examining the immediate innovations of the pandemic and towards long-term adjustments.We used Interpretative Phenomenological Analysis (IPA) to explore the experiences of trainees in paediatric cardiology during the pandemic. Five trainees were purposively recruited. Initial semi-structured interviews were held during the first wave of the pandemic with follow-up interviews held during the second wave.Three superordinate paradoxical themes were recognised in the data: connectedness and isolation, disruption and stasis and vulnerability and strength.Disruption to routine activities of service delivery, training and home-life pervaded the pandemic and was experienced as stasis. Technology maintained the trainee's connection to the content of work but left them feeling isolated from its context. Vulnerability arose from interplay between illness, uncertainty and perception of risk, contrasted against strength drawn from compassion and the discovery of resilience. Supporting trainees as we emerge from the initial phase of the pandemic requires us to review how we understand and address wellness, including the contribution of organisational and systemic factors to its protection. Participants described varying states of impaired wellness and experienced a normalisation of aspects of vulnerability. We theorise that trainees were able to find opportunities for growth and the development of resilience within the space that this created.

CONTEXT: Residents need their supervisors in the operating room to inform them on how to use their expertise in present and future occasions. A few studies hint at such explicit teaching behaviour, however without explaining its underlying mechanisms. Understanding and improving explicit teaching becomes more salient nowadays, as access of residents to relevant procedures is decreasing, while end-terms of training programs remain unchanged: high quality patient care.OBJECTIVES: A structured analysis of 1. The practices supervisors use for explicit teaching and 2. How supervisors introduce explicit teaching in real time during surgical procedures.METHODS: An observational qualitative collection study in which all actions of nine supervisor-resident dyads during a total hip replacement procedure were videotaped. Interactions in which supervisors explicitly or implicitly inform residents how to use their expertise now and in future occasions were included for further analysis, using the iterative inductive process of conversation analysis.RESULTS: 1. Supervisors used a basic template of if/then rules for explicit teaching, which they regularly customized by adding metaphors, motivations, and information about preference, prevalence and consequence. 2. If/then rules are introduced by supervisors to solve a (potential) problem in outcome for the present patient in reaction to local circumstances, e.g. what residents said, did or were about to do.CONCLUSIONS: If/then rules add the why to the what. Supervisors upgrade residents' insights in surgical procedures (professional vision) and teach the degree of individual freedom and variation of their expert standards for future occasions. These insights can be beneficial in improving supervisors' teaching skills.

Differential rater function over time (DRIFT) and contrast effects (examiners' scores biased away from the standard of preceding performances) both challenge the fairness of scoring in objective structured clinical exams (OSCEs). This is important as, under some circumstances, these effects could alter whether some candidates pass or fail assessments. Benefitting from experimental control, this study investigated the causality, operation and interaction of both effects simultaneously for the first time in an OSCE setting.We used secondary analysis of data from an OSCE in which examiners scored embedded videos of student performances interspersed between live students. Embedded video position varied between examiners (early vs. late) whilst the standard of preceding performances naturally varied (previous high or low). We examined linear relationships suggestive of DRIFT and contrast effects in all within-OSCE data before comparing the influence and interaction of 'early' versus 'late' and 'previous high' versus 'previous low' conditions on embedded video scores.Linear relationships data did not support the presence of DRIFT or contrast effects. Embedded videos were scored higher early (19.9 [19.4-20.5]) versus late (18.6 [18.1-19.1], p 0.001), but scores did not differ between previous high and previous low conditions. The interaction term was non-significant.In this instance, the small DRIFT effect we observed on embedded videos can be causally attributed to examiner behaviour. Contrast effects appear less ubiquitous than some prior research suggests. Possible mediators of these finding include the following: OSCE context, detail of task specification, examiners' cognitive load and the distribution of learners' ability. As the operation of these effects appears to vary across contexts, further research is needed to determine the prevalence and mechanisms of contrast and DRIFT effects, so that assessments may be designed in ways that are likely to avoid their occurrence. Quality assurance should monitor for these contextually variable effects in order to ensure OSCE equivalence.

Introduction: \ud International Medical Graduates (IMGs) represent a large portion of practicing doctors in many countries. Many experience difficulties, including higher rates of complaints against them and lower exam pass rates. The UK’s General Medical Council (GMC) recently set targets to ‘eliminate disproportionate complaints’ and ‘eradicate disadvantage and discrimination in medical education’. Our timely meta-ethnography aimed to synthesise existing qualitative literature on the wider personal and professional experiences of IMGs, to identify factors affecting IMGs’ professional practice (either directly or indirectly).\ud \ud Methods: \ud In September 2019 we systematically searched Medline, Embase, Cochrane, PsycINFO, ERIC and EdResearch for peer-reviewed qualitative and mixed-methods articles that described experiences of IMGs. We extracted participant quotes and authors’ themes from included articles and used the technique of meta-ethnography to synthesise the data and develop new overarching concepts.\ud \ud Results: \ud Of the 1613 articles identified, 57 met our inclusion criteria. In total, the articles corresponded to 46 studies that described the experiences of 1142 IMGs practicing in all 6 continents in a range of settings, including primary and secondary care. We developed 5 key concepts: Migration dimensions (issues considered by IMGs when migrating), a challenging start (the stressful early period), degree of dissonance (between the IMG and host country in relation to the 4 main barriers of language, culture, medical education and belonging), levelling the playing field (interventions to reduce the impact of the barriers) and survive then thrive (adjustments IMGs made). A conceptual model that brings these constructs together in a line of argument is presented.\ud \ud Conclusions: \ud This meta-ethnography, based on a large amount of diverse qualitative studies, is the first to provide a comprehensive picture of the experiences and challenges that IMGs face before and after migration. Our results should be used to guide the development of interventions aiming to support IMGs and meet the GMC targets.

Introduction: Longitudinal Integrated Clerkships (LICs) have demonstrated benefits for students' learning and development in medical education globally. The model emphasises importance with respect to continuity and time in the workplace for learners. There is a need to explore how LICs become a viable training model for learners. An amalgamative LIC model was drawn upon to inform the design of a placement for trainee pharmacists on a hospital ward. This study sought to determine the local viability of a longitudinal placement for trainee pharmacists, using communities of practice learning theory to interpret findings. Methods: A design-based research approach informed study design. A longitudinal placement was implemented on two hospital wards for 13 weeks. Trainees (n = 3) were interviewed four times over a 14-week period. Ward staff (n = 14) were interviewed at week 14. Interviews were transcribed verbatim. Qualitative longitudinal analysis, using the trajectory approach, was conducted using abductive analysis. The coded data were organised into a framework and subthemes were created. Results: Trainees acquired membership within the multi-disciplinary ward team over time. This led to an enriched learning experience and the trainee's professional development improved as they attained more responsibilities. This enabled them to make a greater contribution to patient care; more medication consultations occurred, and discharge times improved. Discussion: The local viability of the longitudinal placement appears to be linked to the trainee's ability to acquire membership within the ward community of practice. Membership gave trainee's access to learning opportunities, supporting their development, and they earnt the trust of staff, leading to more responsibilities for providing patient care. Further research into developing longitudinal placements that support trainee healthcare professionals to acquire membership within communities of practice is warranted.

Context Professionalism lapses have high stakes for learners and educators. Problems with professionalism, unless appropriately and effectively remediated, may portend serious problems in practice. Yet, remediation for unprofessional behaviour is particularly challenging-and understudied. Increasingly, educators are turning to reflective writing as a remediation strategy in residency, yet little is known about what educators expect reflective writing to accomplish, how they choose reflective writing tasks, why they use reflective writing, or how they evaluate whether a learner has met expectations. We aimed to understand why and how postgraduate medical educators use reflective writing as an educational intervention to remediate professionalism. Method In this constructivist grounded theory study, we interviewed 13 medical education professionals with experience using reflective writing to remediate professionalism across five Canadian medical schools. Data collection and analysis occurred iteratively using constant comparison to identify themes and to understand the relationships among them. Results Medical educators reported using reflective writing as a learning tool to develop insight and as an assessment tool to unearth evidence of insight. The goal of learning may compete with the goal of assessment, creating tension that leads to uncertainty about the sincerity, quality, and effectiveness of reflective writing as well as concerns about learner safety. Educators reported uncertainty about whether learners write to pass or to introspect and about how to judge the effectiveness of reflective writing as a learning tool. They expressed concern about creating a safe environment for learners-one that enables the genuine reflection required for insight development-while meeting requirements of remediation. Conclusions Educators express ambivalence about using reflective writing to remediate professionalism in residency. Understanding the potential and pitfalls of reflective writing may inform more tailored and effective approaches to remediate professionalism.

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

Research has shown that taking ‘timeouts’ in medical practice improves performance and patient safety. However, the benefits of taking timeouts, or pausing, are not sufficiently acknowledged in workplaces and training programmes. To promote this acknowledgement, we suggest a systematic conceptualisation of the medical pause, focusing on its importance, processes and implementation in training programmes. By employing insights from educational and cognitive psychology, we first identified pausing as an important skill to interrupt negative momentum and bolster learning. Subsequently, we categorised constituent cognitive processes for pausing skills into two phases: the decision‐making phase (determining when and how to take pauses) and the executive phase (applying relaxation or reflection during pauses). We present a model that describes how relaxation and reflection during pauses can optimise cognitive load in performance. Several strategies to implement pause training in medical curricula are proposed: intertwining pause training with training of primary skills, providing second‐order scaffolding through shared control and employing auxiliary tools such as computer‐based simulations with a pause function., Lee et al. suggest a systematic conceptualization of the medical pause, focusing on its importance, processes, and implementation in training programs.

In this issue, Stephens et al. present their investigation into medical students' experiences of uncertainty.1 Although clinical uncertainty is ubiquitous in medical practice, development of uncertainty tolerance is too often left implicit, to the detriment of care and caregivers given that intolerance is associated with overuse of resources, burnout and psychological distress. Interestingly, Stephens et al. found that students reported greater experience of educational uncertainty (lack of clarity regarding how and what to learn), and professional uncertainty (who they would be as doctors), than clinical uncertainty (aspects of patient care). That clinical uncertainty was least often reported suggests a need for educators to broaden consideration of uncertainty. Educators should also consider whether the lack of reportage of clinical uncertainty is actually a reflection of students' reduced awareness, rather than reduced experience, of this common phenonenon. As students advance further in their training and develop their clinical reasoning skills, clinical uncertainty will be, as it is for practicing doctors, frequently encountered, leading me to agree with Stephens et al.,1 that greater attention should be paid to clinical uncertainty. In addition, an understanding of the relationship between tolerance of uncertainty and development of clinical reasoning is needed. In order to explore this further, I consider the age old dilemma of what came first, the chicken or the egg: that is, does tolerance of uncertainty derive from or cause improved clinical reasoning?

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.

Context Health professions education (HPE) has increasingly turned to qualitative methodology to address a number of the field's difficult research problems. While several different methodologies have been widely accepted and used in HPE research (e.g., Grounded Theory), others remain largely unknown. In this methodology paper, we discuss the value of narrative analysis (NA) as a set of analytic approaches that offer several lenses that can support HPE scholars' research. Methods After briefly discussing the 'narrative turn' in research, we highlight five NA lenses: holistic, situated, linguistic, agentive and sequential. We explore what each lens can offer HPE scholars-highlighting certain aspects of the data-and how each lens is limited-obscuring other aspects. To support these observations, we offer an example of each lens from contemporary HPE scholarship. The manuscript also describes methods that can be employed in NA research and offers two different typologies of NA methods that can be used to access these lenses. Conclusions We conclude with a discussion of how different analytic methods can be used to harness each of the lenses. We urge the deliberate selection and use of NA methods and point to the inherent partiality of any NA approach. Reflecting on our position as narrative scholars, we acknowledge how our own lenses illuminate some areas and conceal others as we tell the story of NA. In conclusion, we invite other researchers to benefit from the potential NA promises.

CONTEXT Although many medical schools seek to improve diversity, they grapple with the challenge of how to weight the scores of different admission methods to achieve a balance between obtaining high predictiveness and ensuring diversity in the selected student pool. Yet, in large-scale employment settings, substantial progress has been made on this front: Pareto-optimization has been introduced as an elegant statistical tool to assist decision makers in determining the weights assigned to selection methods in advance (before the selection has taken place) so that a selection system is designed to achieve an optimal balance as reflected by the trade-off that one outcome (e.g., predictiveness) cannot be improved without harm to the other outcome (e.g., diversity). AIMS This paper reviews the theory and research evidence about Pareto-optimization and explains how Pareto-optimization permits medical schools to better balance predictiveness and diversity in medical admission systems. METHODS After reviewing common weighting schemes (unit, regression-based and ad hoc weighting) and their drawbacks, we introduce the theory and logic of Pareto-optimization for better balancing predictiveness and diversity. To this end, we also offer an illustrative example. Next, we review the mathematical basis and available research evidence regarding Pareto-optimization. Finally, we discuss potential criticisms (i.e., complexity and legal concerns). CONCLUSIONS Compared to traditional unit weighting, regression-based weighting and ad hoc weighting, Pareto-optimization leads to substantial increases in diversity intake (up to three times more), while keeping the predictiveness of the selection methods at the same level. Moreover, the Pareto-optimization is robust to sampling variability and variability of the input selection parameters.

Background Since 2017 more than 50% of UK doctors have undertaken a ‘Foundation 3 (F3) Year’ training break after completing their Foundation Programme (the first two years following graduation), rather than immediately enter specialty training. The reasons for, and consequences of, the growing F3 trend are largely unknown. This scoping review presents the current evidence and identifies future research in this field. Methods Following Arksey and O’Malley’s guidelines, 12 databases and three UK‐based national post‐graduate organisation websites were searched for articles published in English (final searches January 2020). Multiple search terms were used to capture articles relating to the ‘F3’ time‐period, including ‘post‐foundation’ or ‘pre‐specialty’ training. Title, abstract and full‐paper screening selected articles reporting any aspect of F3, including within a wider context (e.g., postgraduate training breaks), and then underwent mixed methods analysis . Results Of 4766 articles identified, 45 were included. All articles were published after 2009; 14/45 (31.1%) were published in 2019. 27 articles reported research, the remainder were opinion/commentaries. Specific personal (including demographic), professional and organisational factors, particularly the UK post‐graduate training structure, are associated with undertaking an F3. The majority of F3 training breaks last 1 year and involve working (clinically or non‐clinically) and/or travel. The decision to undertake an F3 is made either prior to, or during, foundation training. Evidence regarding the impact of F3 on healthcare service provision was limited but evenly balanced. Conclusions In summarising the existing F3 evidence, this review has highlighted important issues including healthcare workforce equality and diversity, training pathway inflexibility and the effect of negative early‐career experiences on subsequent career decisions. More research is needed to understand the financial impact of training‐breaks on healthcare service provision, how training programmes must adapt to retain more trainees, and the long‐term effects of training breaks, such as F3, on subsequent career progression.

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

Context The trajectory towards becoming a medical professional is strongly situated within the clinical workplace. Through participatory engagement, medical trainees learn to address complex health care issues through collaboration with the interprofessional health care team. To help explain learning and teaching dynamics within the clinical workplace, many scholars have relied on socio‐cultural learning theories. In the field of medical education, this research has largely adopted a limited interpretation of a crucial dimension within socio‐cultural learning theory: the expert who guides the trainee into the community is almost exclusively from the same profession. We contend that this narrow interpretation is not necessary. This limited focus is one we choose to maintain—be that choice intentional or implicit. In this cross‐cutting edge paper, we argue that choosing an interprofessional orientation towards workplace learning and guidance may better prepare medical trainees for their future role in health care practice. Methods By applying Communities of Practice and Landscapes of Practice , and supported by empirical examples, we demonstrate how medical trainees are not solely on a trajectory towards the Community of Physician Practice (CoPP) but also on a trajectory towards various Landscapes of Healthcare Practice (LoHCP). We discuss some of the barriers present within health care organisations and professions that have likely inhibited adoption of the broader LoHCP perspective. We suggest three perspectives that might help to deliberately and meaningfully incorporate the interprofessional learning and teaching dynamic within the medical education continuum. Conclusion Systematically incorporating Landscapes of Competence, Assessment, and Guidance in workplace‐based education—in addition to our current intraprofessional approach—can better prepare medical trainees for their roles within the LoHCP. By advocating and researching this interprofessional perspective, we can embark on a journey towards fully harnessing and empowering the health care team within workplace‐based education., Using a Landscapes of Health Care Practices perspective, the authors describe how medical education should be feeding both and intra‐ and interprofessional perspectives on effective workplace learning.

Colonnello offers the affective neuroscience view as a means for better understanding the role of emotions in remediation and nurturing synergistic interactions between research and education.

Introduction: Previous research suggests that, relative to generating a differential diagnosis, deliberate reflection during practice with clinical cases fosters learning from a subsequently studied scientific text and promotes interest in the subject matter. The present experiment aimed to replicate these findings and to examine whether motivational or cognitive mechanisms, or both, underlie the positive effects of reflection. Methods: A total of 101 5th-year medical students participated in an experiment containing four phases: Students (a) diagnosed two clinical cases of jaundice-related diseases either through deliberate reflection or differential diagnosis; (b) reported their situational interest and awareness of knowledge gaps; (c) studied a text about jaundice, either under free or restricted time; and (d) recalled the text. Outcome measures were text-recall, situational interest and awareness of knowledge gaps. Results: A main effect of diagnostic approach on recall of the text was found, with the reflection group recalling more studied material than the differential diagnosis group (means: 72.56 vs 58.80; P =.01). No interaction between diagnostic approach and study time (free or restricted) emerged, nor was there a main effect of the latter. Relative to the differential diagnosis group, students who reflected upon the cases scored significantly higher on both situational interest (means: 4.45 vs 3.99, P