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

Context: The use of peer support as a faculty development technique to improve clinical teaching is uncommon in medical education, despite the benefits of situating learning in the workplace. The authors therefore conducted a broad search seeking theoretical and empirical literature describing peer support strategies for clinical teachers in health care workplaces. This included descriptive and non‐experimental studies that are often excluded from reviews. The review aimed to identify and assess existing initiatives and to synthesise key challenges and benefits. Methods: An integrative literature review was undertaken (2004–2017), based on searches of eight international electronic databases and targeted manual searches. Key concepts, elements and models were mapped using an iterative, constant comparative method. An evaluative framework, drawing on previous research, informed conclusions regarding the quality of evidence. Results: From a pool of 5735 papers, 34 met the inclusion criteria. The majority referred to studies conducted in the USA (59%) and in the medical profession (71%). Analysis revealed a trend towards using a collaborative model (56%), voluntary participation (59%), and direct workplace observation by a peer clinician (68%). Design features of the peer support strategy were commonly reported (65%), with half providing outcome measures (56%). Few papers reported on process evaluation (15%) or evidence of programme sustainability (15%). Despite logistical and time‐associated challenges, benefits accrued to individuals and the workplace, and included improved teaching practices. Embedding the peer support strategy into routine organisational practice proved effective. Conclusions: The results indicated that a workplace‐based peer support model is an acceptable and effective faculty development strategy for health care clinical teachers. Conceptualising workplace‐based peer support via a sociocultural model that acknowledges the significance of educational design, peers as collaborators and the importance of workplace context and culture is emphasised. Future research should focus on clarification studies informed by contemporary models of faculty development, in which factors impacting the health care workplace are considered. By reviewing the literature, Campbell et al. highlight how collaborative relationships and workplace connections with peers offer an under‐utilized resource for effectively improving teaching expertise. [ABSTRACT FROM AUTHOR]

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

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

Objectives: As educational theories are increasingly used in medical education research there are concerns over how these theories are used, how well they are presented and what the authors intend. Communities of practice (CoP) is one example of an often‐used theory and conceptual framework. This paper presents a critical analysis of how CoP theory is used in medical education research. Methods: A critical literature analysis was undertaken of articles published between 1998 and 2018 in eight internationally recognised medical education journals. From a total of 541 articles, 80 articles met the inclusion criteria and were analysed and mapped according to various patterns of use. Results: We discerned five categories of use, two misleading and cosmetic, off target and cosmeticising, and three functional, framing, lensing and transferring. A considerable number of articles either misrepresented the point of communities of practice or used it in a cosmetic fashion. The remainder used the theory to frame an ongoing study in relation to other work, as a lens through which to design the study and collect or analyse data, or as a way of discussing or demonstrating the transferability of the findings. Conclusions: We conclude that almost half of the reviewed articles did not offer a functional and rigorous definition of what is meant by CoP; instead, they used it in a potentially misleading or cosmetic manner. This study therefore calls on editors, reviewers and authors alike to increase clarity and quality in the application of CoP theory in medical education. McGrath et al. use Communities of Practice literature to analyze how theory is used in health professional education. Their findings? Often in a predominantly cosmetic way, requiring more critical thought about how to advance our research strategies. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare systems worldwide are facing a workforce crisis; meanwhile, refugee doctors throughout the world face difficulties in accessing work. The aims of this review were to explore the integration needs of refugee doctors into host healthcare systems from the refugee perspective, synthesise the literature to construct a theory of refugee doctor integration needs and explore how these needs are met or challenged on the pathway to full integration. Methods: In this integrative literature review, 11 databases and eight grey literature sources were searched by combining terms for refugee doctor and social integration and limiting to research published in or after 2003. Data were extracted, and quality scoring was completed independently by two researchers. This study utilised template analysis to perform a qualitative synthesis of the data. The multidimensional template included a pre‐defined template based on a theoretical framework and a concurrent fully inductive template. Results: Twenty‐two papers were included, incorporating the views of 339 doctors from 30 different home countries and 10 different host countries. The resultant theory included 'foundations' (rights and responsibilities) and three pillars. The 'learning' pillar included required knowledge and skills acquisition. The 'being' pillar encompassed necessary identity work. The 'connecting' pillar comprised social connections, which impacted all other domains. The random and non‐linear path to integration faced by refugee doctors was also presented as a serious game. Discussion: This study produced a theory exploring refugee doctors' integration needs and how these are met or challenged. Medical educators developing courses for refugee doctors should attend not only to knowledge and skills acquisition but also social connections, identity work and rights and responsibilities. The theory highlights the central importance of social connections. Medical educators can therefore have a transformative impact on refugee doctors' integration. This may also contribute to society by helping to alleviate the workforce crisis. This integrative review article explores refugee doctors' workforce integration needs introducing use a serious game into the analysis. [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]

Introduction: Much published research writing is dull and dry at best, impenetrable and off‐putting at worst. This state of affairs both frustrates readers and impedes research uptake. Scientific conventions of objectivity and neutrality contribute to the problem, implying that 'good' research writing should have no discernible authorial 'voice'. Yet some research writers have a distinctive voice in their work that may contribute to their scholarly influence. In this study, we explore this notion of voice, examining what strong research writers aim for with their voice and what strategies they use. Methods: Using a combination of purposive, snowball and theoretical sampling, we recruited 21 scholars working in health professions education or adjacent health research fields, representing varied career stages, research paradigms and geographical locations. We interviewed participants about their approaches to writing and asked each to provide one to three illustrative publications. Iterative data collection and analysis followed constructivist grounded theory principles. We analysed interview transcripts thematically and examined publications for evidence of the writers' described approaches. Results: Participants shared goals of a voice that was clear and logical, and that engaged readers and held their attention. They accomplished these goals using approaches both conventional and unconventional. Conventional approaches included attention to coherence through signposting, symmetry and metacommentary. Unconventional approaches included using language that was evocative (metaphor, imagery), provocative (pointed critique), plainspoken ('non‐academic' phrasing), playful (including humour) and lyrical (attending to cadence and sound). Unconventional elements were more prominent in non‐standard genres (e.g. commentaries), but also appeared in empiric papers. Discussion: What readers interpret as 'voice' reflects strategic use of a repertoire of writing techniques. Conventional techniques, used expertly, can make for compelling reading, but strong writers also draw on unconventional strategies. A broadened writing repertoire might assist health professions education research writers in effectively communicating their work. Make your next research manuscript more engaging & memorable. This qualitative study of 21 health research writers offers a repertoire of conventional & unconventional strategies you can try. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 1215-1225 Context Mapping is a means of representing knowledge in a visual network and is becoming more commonly used as a learning strategy in medical education. The assumption driving the development and use of concept mapping is that it supports and furthers meaningful learning. Objectives The goal of this paper was to examine the effectiveness of concept mapping as a learning strategy in health professions education. Methods The authors conducted a critical analysis of recent literature on the use of concept mapping as a learning strategy in the area of health professions education. Results Among the 65 studies identified, 63% were classified as empirical work, the majority (76%) of which used pre-experimental designs. Only 24% of empirical studies assessed the impact of mapping on meaningful learning. Results of the analysis do not support the hypothesis that mapping per se furthers and supports meaningful learning, memorisation or factual recall. When documented improvements in learning were found, they often occurred when mapping was used in concert with other strategies, such as collaborative learning or instructor modelling, scaffolding and feedback. Conclusions Current empirical research on mapping as a learning strategy presents methodological shortcomings that limit its internal and external validity. The results of our analysis indicate that mapping strategies that make use of feedback and scaffolding have beneficial effects on learning. Accordingly, we see a need to expand the process of reflection on the characteristics of representational guidance as it is provided by mapping techniques and tools based on field of knowledge, instructional objectives, and the characteristics of learners in health professions education. [ABSTRACT FROM AUTHOR]

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

Background: Artificial intelligence (AI) is becoming increasingly used in medical education, but our understanding of the validity of AI‐based assessments (AIBA) as compared with traditional clinical expert‐based assessments (EBA) is limited. In this study, the authors aimed to compare and contrast the validity evidence for the assessment of a complex clinical skill based on scores generated from an AI and trained clinical experts, respectively. Methods: The study was conducted between September 2020 to October 2022. The authors used Kane's validity framework to prioritise and organise their evidence according to the four inferences: scoring, generalisation, extrapolation and implications. The context of the study was chorionic villus sampling performed within the simulated setting. AIBA and EBA were used to evaluate performances of experts, intermediates and novice based on video recordings. The clinical experts used a scoring instrument developed in a previous international consensus study. The AI used convolutional neural networks for capturing features on video recordings, motion tracking and eye movements to arrive at a final composite score. Results: A total of 45 individuals participated in the study (22 novices, 12 intermediates and 11 experts). The authors demonstrated validity evidence for scoring, generalisation, extrapolation and implications for both EBA and AIBA. The plausibility of assumptions related to scoring, evidence of reproducibility and relation to different training levels was examined. Issues relating to construct underrepresentation, lack of explainability, and threats to robustness were identified as potential weak links in the AIBA validity argument compared with the EBA validity argument. Conclusion: There were weak links in the use of AIBA compared with EBA, mainly in their representation of the underlying construct but also regarding their explainability and ability to transfer to other datasets. However, combining AI and clinical expert‐based assessments may offer complementary benefits, which is a promising subject for future research. Is artificial intelligence (AI) ready to replace clinicians in clinical skills assessment? In this paper, Johnsson et al. use Kane's framework to compare validity evidence between the two. [ABSTRACT FROM AUTHOR]

Introduction: 'Fit' refers to an applicants' perceived compatibility to a residency programme. A variety of structural, identity‐related and relational factors contribute to self‐assessments of fit. The 2021 residency recruitment cycle in the USA was performed virtually due to the COVID‐19 pandemic. Little is known about how video‐interviewing may affect residency applicants' ability to gauge fit. Methods: A multidisciplinary, anonymous survey was distributed to applicants at a large academic institution between rank order list (ROL) certification deadline and Match Day 2021. Using Likert‐type scales, applicants rated factors for importance to 'fit' and their ease of assessment through video‐interviewing. Applicants also self‐assigned fit scores to the top‐ranked programme in their ROL using Likert‐type scales with pairs of anchoring statements. Results: Four hundred seventy‐three applicants responded to the survey (25.7% response rate). The three most important factors to applicants for assessment of fit (how much the programme seemed to care, how satisfied residents seem with their programme and how well the residents get along) were also the factors with the greatest discrepancy between importance and ease of assessment through video‐interviewing. Diversity‐related factors were more important to female applicants compared with males and to non‐White applicants compared with White applicants. Furthermore, White male applicants self‐assigned higher fit scores compared with other demographic groups. Conclusion: There is a marked discrepancy between the most important factors to applicants for fit and their ability to assess those factors virtually. Minoritised trainees self‐assigned lower fit scores to their top‐ranked programme, which should raise concern amongst medical educators and highlights the importance of expanding current diversity, equity and inclusion efforts in academic medicine. This paper offers examination of how residency applicants assess fit to the programs at which they interview during the virtual recruitment era, showing that female and minority applicants perceive poorer fit. [ABSTRACT FROM AUTHOR]

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

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

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. This paper highlights the importance of healthcare trainees acquiring membership within healthcare teams to enhance their learning experience, advance their professional development and improve patient care. [ABSTRACT FROM AUTHOR]

The author recalls the article "Assessing Professional Competence: From Methods to Programmes" he co-wrote and published in a 2005 issue of "Medical Education" and the progress made since then. He stresses that most of the assessment methods have their limitations. He warns that attempt to combine such methods in in-training assessments could compromise their reliability. He cites his initiatives to develop the evaluation of assessment programmes in partnership with his colleagues.

Context: Rural community‐based medical education (RCBME), in which medical student learning activities take place within a rural community, requires students, clinical teachers, patients, community members and representatives of health and government sectors to actively contribute to the educational process. Therefore, academics seeking to develop RCBME need to understand the rural context, and the views and needs of local stakeholders. Objectives: The aim of this review is to examine stakeholder experiences of RCBME programmes internationally. Methods: This narrative literature review of original research articles published after 1970 utilises Worley's symbiosis model of medical education as an analysis framework. This model proposes that students experience RCBME through their intersection with multiple clinical, social and institutional relationships. This model seeks to provide a framework for considering the intersecting relationships in which RCBME programmes are situated. Results: Thirty RCBME programmes are described in 52 articles, representing a wide range of rural clinical placements. One‐year longitudinal integrated clerkships for penultimate‐year students in Anglosphere countries were most common. Such RCBME enables students to engage in work‐integrated learning in a feasible manner that is acceptable to many rural clinicians and patients. Academic results are not compromised, and a few papers demonstrate quality improvement for rural health services engaged in RCBME. These programmes have delivered some rural medical workforce outcomes to communities and governments. Medical students also provide social capital to rural communities. However, these programmes have significant financial cost and risk student social and educational isolation. Conclusions: Rural community‐based medical education programmes are seen as academically acceptable and can facilitate symbiotic relationships among students, rural clinicians, patients and community stakeholders. These relationships can influence students’ clinical competency and professional identity, increase graduates’ interest in rural careers, and potentially improve rural health service stability. Formal prospective stakeholder consultations should be published in the literature. [ABSTRACT FROM AUTHOR]

As a reflection on the Edinburgh Declaration, this conceptual synthesis presents six important challenges in relation to the role of medical education in meeting current national health priorities. Context This paper presents a conceptual synthesis of current efforts in medical education to incorporate national health priorities as a reflection on how the field has evolved since the Edinburgh Declaration. Considering that health needs vary from country to country, our paper focuses on three broad and cross-cutting themes: health equity, health systems strengthening, and changing patterns of disease. Methods Considering the complexity of this topic, we conducted a targeted search to broadly sample and critically review the literature in two phases. Phase 1: within each theme, we assessed the current challenges in the field of medical education to meet the health priority. Phase 2: a search for various strategies in undergraduate and postgraduate education that have been tested in an effort to address the identified challenges. We conducted a qualitative synthesis of the literature followed by mapping of the identified challenges within each of the three themes with targeted efforts. Findings We identified six important challenges: (i) mismatch between the need for generalist models of health care and medical education curricula's specialist focus; (ii) attitudes of health care providers contributing to disparities in health care; (iii) the lack of a universal approach in preparing medical students for 21st century health systems; (iv) the inability of medical education to keep up with the abundance of new health care technologies; (v) a mismatch between educational requirements for integrated care and poorly integrated, specialised health care systems; and (vi) development of a globally interdependent education system to meet global health challenges. Examples of efforts being made to address these challenges are offered. Discussion Although strategies for combatting these challenges exist, the effectiveness of educational models depends on them being locally adaptable and applicable. Curricular reform must go hand-in-hand with research and evaluation to develop comprehensive futuristic models of teaching and learning that will adequately prepare health professionals to address the challenges. [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: Medical education and workplace learning is bound to develop through tensions between providing high quality patient care and providing training of the future specialist healthcare workforce. This paper on the Change Laboratory and the theoretical framework supporting it, shows examples on how to explore inherent and contradictory tensions in medical education and healthcare and use them as a driving force for change. We argue that the traditional tools and theories for change and fixing tensions are inadequate and therefore suggest an alternative strategy found in Cultural‐Historical Activity Theory (CHAT) and the Change Laboratory method. Methods: The Change Laboratory intervention method builds on the theoretical framework of CHAT and specifically the theory of expansive learning. The Change Laboratory intervention method uses well‐defined steps for participants in collaboration with researchers/facilitators to co‐construct and develop new ways of going about their work practice. Results: Drawing on our own research on implementing the Change Laboratory intervention method we present two case examples of interventions in respectively a Finnish surgical unit and a Danish paediatric outpatient clinic. Conclusions: The Change Laboratory intervention offers ways to systematically leverage tensions in medical education and thus could be effective in developing and designing organisational and professional change. It is not a quick fix solution as participators must be motivated and engaged in uncovering inherent contradictions in their activity systems (workplace) and get familiar with the concepts and theory underlying the intervention and its procedures. Profound knowledge and transformative agency emerges when participants and facilitators/researchers are given the time and opportunity to analyse both historical practice, current data on practice, and organisational issues collaboratively in order to envision and redesign their practice and learning environment. The Change Laboratory intervention offers ways to leverage tensions in medical education to help design change in participants practice and learning environment. [ABSTRACT FROM AUTHOR]

Context The arts and humanities are gradually gaining a foothold in health professions education as a means of supporting the development of future clinicians who are compassionate, critical and reflexive thinkers, while also strengthening clinical skills and practices that emphasise patient-centredness, collaboration and interprofessional practices. Assignments that tap into trainee creativity are increasingly used both to prepare learners for the demands of clinical work and to understand the personal and professional challenges learners face in these contexts. Health professions educators need methods for interpreting these creations in order to understand each learner's expressions. This paper describes two theoretical frameworks that can be used to understand trainees' unique learning experiences as they are expressed in arts- and humanities-based creations. Methods The authors introduce the philosophical underpinnings and interpretation procedures of two theoretical frameworks that enable educators to 'hear' and 'see' the multilayered expressions embedded within arts- and humanities-based student creations: Gilligan's Listening Guide and Kress and van Leeuwen's approach to visual rhetoric. To illustrate how these frameworks can be used, the authors apply them to two creative summaries that learners made as part of a humanities-informed, interprofessional education intervention that took place in a non-acute-care teaching hospital. The interpretations of two creative summaries, a poem and a pair of paintings, highlight how applying these theoretical frameworks can offer important insights into learners' experiences. Conclusions This cross-cutting edge paper describes how the Listening Guide and visual rhetoric can help health professions educators listen to and read the arts- and humanities-based creative expressions made by learners. Insights gained from these interpretations can advance the understanding of students' personal experiences in different learning environments and can inform curriculum development. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 838-849 Context The effect of teamwork on team performance is broadly recognised in the medical field. This recognition is manifested in educational programmes in which attention to interpersonal behaviours during teamwork is growing. Conflict and power differences influence interpersonal behaviours and are marked topics in studies of group functioning in the social and organisational psychology literature. Insights from the domain of social sciences put the ongoing improvement of teamwork into broader perspective. Objectives This paper shows how knowledge from the domain of social and organisational psychology contributes to the understanding of teamwork in the medical environment. More specifically, this paper suggests that unfolding the underlying issues of power and conflict within medical teams can be of extra help in the development of educational interventions aimed at improving team performance. Methods We review the key social psychology and organisational behaviour literature concerning power and conflict, and relate the insights derived from this to the team process of ad hoc medical action teams. Results We present a theoretical framework in which insights into power and conflict are used to explain and predict team dynamics in ad hoc medical action teams. Conclusions Power and conflict strongly influence interpersonal behaviour. Characteristics of medical action teams give rise to all kinds of issues of disagreement and are accompanied by complex issues of intra-team power distribution. We argue that how team members coordinate, cooperate and communicate is steered by members' personal motivations, which, in turn, strongly depend on their perceptions of power and conflict. Given the importance of the performance of these teams, we suggest future directions for the development of training interventions building on knowledge and theories derived from social and organisational psychology. [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: Every diagnosis involves an act of decision making, which requires proper evaluation of information. However, even seemingly objective information can require interpretation, often without our conscious awareness. In this cross‐cutting edge article we describe the phenomenon of leader‐driven information distortion (ID) and its implications for medical education. Information distortion: Recent research indicates that one threat to good decisions is a biased interpretation of information to favour one alternative course of action over another. Once an alternative emerges as a leader during a decision there is a strong tendency to evaluate subsequent information as supporting that option. This can occur when deciding between two competing diagnoses. It is particularly a concern if diagnostic tests provide potentially ambiguous results. This leader‐driven ID is pre‐decisional in nature, in that it develops during a decision and involves the interpretation of information available prior to the final decision or diagnosis, with different interpretations possible depending on whichever alternative is the leader. Studies reveal that the distortion bias is pervasive in decisions, and that awareness of the act of distortion is low in decision makers. Application to medical education: Empirical research has confirmed the presence of leader‐driven ID in hypothetical diagnoses made by physicians. ID creates two threats to medical decisions: First, it can make a diagnosis sticky in that it is resistant to being overturned by contradictory information. Second, it can promote unwarranted certainty in a diagnosis. The outcome may be premature closure, unnecessary testing or incorrect treatment, resulting in delayed or missed diagnoses. Methods: This paper summarises research related to leader‐driven ID in medical and professional decisions and discusses various approaches directed towards reducing ID. A framework and language are provided for thinking about and discussing ID in medical decisions and medical education. Courses of action for mitigating the effects of ID are suggested. Boyle and Purdon review what is known about leader‐driven information distortion, a decision‐bias that can lead physicans to premature closure, unnecessary testing, incorrect treatment, or overconfidence resulting in delayed or missed diagnoses. [ABSTRACT FROM AUTHOR]

Context: The shift in medical education from time‐based learning to outcome‐based learning has drawn much attention to entrustable professional activities (EPAs) as an ideal assessment framework to translate competencies into clinical practice. Given the relative novelty of EPAs, this review aims to highlight research gaps and explore and consolidate available evidence pertaining to the development and implementation of EPAs in health care. Method: Arksey and O'Malley's scoping review framework was used to present the findings. The authors performed a systematic search of PubMed, Embase, CINAHL, Scopus, MedNar, OpenGrey and ProQuest Dissertation and Theses for English articles published from the inception of each database to May 2018. A manual search of the reference lists of the included studies was conducted and an expert panel was consulted. Two reviewers screened the articles for eligibility using the inclusion criteria. All authors extracted key data and analysed the data descriptively. Thematic analysis was used to categorise the results into themes. Results: Eighty articles were included in the review. All articles were published between 2010 and 2018. Three major themes and eight sub‐themes were generated: (i) development of EPAs (frameworks for EPA development and implementation, identifying core or specialty‐specific EPAs, and EPAs for faculty development), (ii) evaluation of EPAs and EPA entrustment factors (revised curriculum, entrustment decisions for professional activities, and feedback on implemented EPAs and the development process), and (iii) future directions and recommendations for EPAs (implementation of EPAs in undergraduate medical education and specific disciplines, and other criticisms and recommendations for EPAs). Conclusions: Entrustable professional activities are an essential means to translate competencies into observable and measurable clinical practice. However, high‐level evidence‐based research on the efficacy, development and implementation of EPAs for specific target groups (i.e. undergraduates and staff) and geographical regions (i.e. Asia and Africa) is still lacking, which suggests a direction for future research. By reviewing the literature on Entrustable Professional Activities, Shorey et al. highlight an urgent need for high‐level evidence‐based research on the efficacy, development and implementation of EPAs for specific target groups. [ABSTRACT FROM AUTHOR]

Context: Transformative learning (TL) has been described as learning that challenges established perspectives, leading to new ways of being in the world. As a learning theory it has resonated with educators globally, including those in the health professions. Described as a complex metatheory, TL has evolved over time, eliciting divergent interpretations of the construct. This scoping review provides a comprehensive synthesis of how TL is currently represented in the health professions education literature, including how it influences curricular activities, to inform its future application in the field. Methods: Arksey and O'Malley's six‐step framework was adopted to review the period from 2006 to May 2018. A total of 10 bibliographic databases were searched, generating 1532 potential studies. After several rounds of review, first of abstracts and then of full texts, 99 studies were mapped by two independent reviewers onto the internally developed data extraction sheet. Descriptive information about included studies was aggregated. Discursive data were subjected to content analysis. Results: A mix of conceptual and empirical research papers, which used a range of qualitative methodologies, were included. Studies from the USA, the UK and Australia were most prevalent. Insights relating to how opportunities for TL were created, how it manifests and influences behaviour, as well as how it is experienced, demonstrated much congruency. Conceptions of TL were seen to be clustered around the work of key theorists. Conclusions: The training of health professionals often takes place in unfamiliar settings where students are encouraged to be active participants in providing care. This increases the opportunity for exposure to learning experiences that are potentially transformative, allowing for a pedagogy of uncertainty that acknowledges the complexity of the world we live in and questions what we believe we know about it. TL provides educators in the health professions with a theoretical lens through which they can view such student learning. This scoping review enhances understanding of transformative learning by exploring ways in which it has been represented in the health professions education literature. [ABSTRACT FROM AUTHOR]

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

Objectives: 'Wicked problems' are complex in nature, have innumerable causes associated with multiple social environments and actors with unpredictable behaviour and outcomes, and are difficult to define or even resolve. This paper considers why and how the frameworks of complexity theory and wicked problems can help medical educators consider selection and widening access (WA) to medicine through fresh eyes to guide future policy and practice. We illustrate how 'wickedity' can frame the key issues in this area, and then address steps that education stakeholders might take to respond to and act on these issues. Methods: We used the 10 properties of a wicked problem to frame common issues in the broad field of selection and WA in medicine. We drew heavily on literature from different disciplines, particularly education, and, through debate and reflection, agreed on the applicability of the theory for illuminating and potentially addressing outstanding issues in selection and WA. Results: Framing medical school selection using the 10 properties of wicked problems is a means of shifting thinking from erroneous 'simple' solutions to thinking more contextually and receptively. The wicked problem framework positions selection as a multi‐causal, complex, dynamic, social problem and foregrounds stakeholders' views and context as being highly relevant in medical school selection. Conclusions: The wicked problem lens shifts thinking and action from seeking one elusive, objective truth to recognising the complexity of medical school selection, managing uncertainty, questioning and considering 'issues' associated with medical school selection more productively. Although there are criticisms of this framework, labelling medical selection as 'wicked' provides original insights and genuine reframing of the challenges of this important, and high profile, aspect of medical education. Doing so, in turn, opens the door to different responses than would be the case if selection and WA were simple and readily tamed. By discussing how complexity theory and the "wicked problems" framework can help medical educators consider selection and widening access the authors provide a new lens to guide policy and practice. [ABSTRACT FROM AUTHOR]

Objectives The goals of this paper are to review the literature on feedback-seeking behaviour using a self-motives framework and to provide practical recommendations for medical educators on how to encourage feedback-seeking behaviour. Methods To gain a better understanding of feedback-seeking behaviour, we apply a self-motives framework. Through this conceptual lens, we define feedback-seeking behaviour and review its antecedents and consequences. We provide an overview of the key findings and answer to a number of unresolved issues in the literature. Results On the basis of the literature review, we present six evidence-based insights to encourage feedback-seeking behaviour in practice. Conclusions The literature review shows that feedback-seeking behaviour is a valuable resource for individuals in work and educational settings as it aids their adaptation, learning and performance. Several individual and contextual factors that promote the seeking of feedback are presented. Although feedback-seeking behaviour has been a subject of research for over 25 years, some unresolved issues remain. We present a self-motives framework to resolve those issues and to stimulate future research. We conclude this paper with six actionable insights for medical educators based on the evidence reviewed. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 545-551 Context Most US medical schools have instituted cultural competence education in the undergraduate curriculum. This training is intended to improve the quality of care that doctors, the majority of whom are White, deliver to ethnic and racial minority patients. Research into the outcomes of cultural competence training programmes reveals that they have been largely ineffective in improving doctors' skills. In varied curricular formats, programmes tend to teach group-specific cultural knowledge, despite the vast heterogeneity of racial and ethnic groups. This cultural essentialism diminishes training effectiveness. Methods This paper proposes key curriculum content changes and suggests the inclusion of an intersectional framework in the cultural competence curriculum. This framework maintains that racial and ethnic minority groups hold multiple social statuses, called social locations, which interact with one another to uniquely shape the health views, needs and experiences of the individuals within the groups. Social locations include those defined by race, ethnicity, gender, social class and sexuality, which are experienced multiplicatively, not additively, within a particular social context. Cultural competence education must go beyond simplified cultural understandings to explore these more complex meanings. Doctors' ability to understand, communicate with and treat diverse groups can be vastly improved by applying an intersectional framework in academic research, self-awareness exercises and clinical training. Results Integrating an intersectional framework into cultural competency education can better prepare doctors for caring for racial and ethnic minority patients. This paper recommends curriculum elements for the classroom and clinical training that can improve doctor knowledge and skills for caring for diverse groups. Medical schools can use the proposed model to facilitate the development of new educational strategies and learning experiences. These improvements can lead to more equitable care and ultimately diminish disparities in health care. Although these recommendations are designed with US schools in mind, they may improve doctor understanding and care of marginal populations across the world. [ABSTRACT FROM AUTHOR]

Context We teach judgement in pieces; that is, we talk about each aspect separately (patient, plan, resources, technique, etc.). We also let trainees figure out how to put the pieces together. In complex situations, this might be problematic. Using data from a drawing-based study on surgeons' experiences with complex situations, we explore the notion of 'problem definition' in real-world clinical judgement using the theoretical lens of systems engineering. Methods 'Emergence', the sensitising concept for analysis, is rooted in two key systems premises: that person and context are inseparable and that what emerges is an act of choice. Via a 'gallery walk' we used these premises to perform analysis on individual drawings as well as cross-comparisons of multiple drawings. Our focus was to understand similarities and differences among the vantage points used by multiple surgeons. Results In this paper we challenge two assumptions from current models of clinical judgement: that experts hold a fixed and static definition of the problem and that consequently the focus of the expert's work is on solving the problem. Each situation described by our participants revealed different but complementary perspectives of what a surgical problem might come to be: from concerns about ensuring standard of care, to balancing personal emotions versus care choices, to coordinating resources, and to maintaining control while in the midst of personality clashes. Conclusion We suggest that it is only at the situation and system level, not at the individual level, that we are able to appreciate the nuances of defining the problem when experts make judgements during real-world complex situations. [ABSTRACT FROM AUTHOR]

Objective The focus of simulation-based education ( SBE) research has been limited to outcome and effectiveness studies. The effect of social and cultural influences on SBE is unclear and empirical work is lacking. Our objective in this study was to explore and understand the complexity of context and social factors at a surgical boot camp ( BC). Methods A rapid ethnographic study, employing the theoretical lenses of complexity and activity theory and Bourdieu's concept of 'capital', to better understand the socio-cultural influences acting upon, and during, two surgical BCs, and their implications for SBE. Over two 4-day BCs held in Scotland, UK, an observer and two preceptors conducted 81 hours of observations, 14 field interviews and 11 formal interviews with faculty members ( n = 10, including the lead faculty member, session leaders and junior faculty members) and participants ( n = 19 core surgical trainees and early-stage residents). Results Data collection and inductive analysis for emergent themes proceeded iteratively. This paper focuses on three analytical themes. First, the complexity of the surgical training system and wider health care education context, and how this influenced the development of the BC. Second, participants' views of the BC as a vehicle not just for learning skills but for gaining 'insider information' on how best to progress in surgical training. Finally, the explicit aim of faculty members to use the Scottish Surgical Bootcamp to welcome trainees and residents into the world of surgery, and how this occurred. Conclusions To the best of our knowledge, this is the first empirical study of a surgical BC that takes a socio-cultural approach to exploring and understanding context, complexities, uncertainties and learning associated with one example of SBE. Our findings suggest that a BC is as much about social and cultural processes as it is about individual, cognitive and acquisitive learning. Acknowledging this explicitly will help those planning similar enterprises and open up a new perspective on SBE research. [ABSTRACT FROM AUTHOR]

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

Introduction The 1964 revision of the Hippocratic Oath addressed the disconnection in language and context between the classical doctrine and 20th century medicine. Now, 50 years later, we argue that any revision of the Oath must be responsive to the significant social, technical and political changes that have occurred in health care. The context for the Hippocratic Oath This paper examines the ways in which health care and the health professions have changed over the last half-century and describes a range of environmental and contextual features that expose the inadequacies of the 1964 Oath in the worlds of today and the future. We note the constancy of the doctor-patient dyad in contemporary ethical codes and consider from the perspective of patient safety those aspects of care that might fall short of the optimum if the focus on the doctor is retained. We ask whether there is any merit in maintaining a focus on the ethics or professionalism of doctors, or whether more of our attention should be directed towards the ethics of health care itself. Conclusions Patient safety is widely acknowledged as a major health issue. Being open about the interdependency of doctors, the complex socio-political nature of health care, and the inevitability of errors and adverse events need not challenge the authority of the doctor. Rather, openness about both the ways in which medicine has changed and the harms that doctors may (inadvertently) cause might afford medicine the opportunity to build a different relationship with patients (and with society more broadly), that recognises complexity, human fallibility and the uncertainty of medicine. [ABSTRACT FROM AUTHOR]

Context Given the power and pervasiveness of technology, this paper considers whether it can help doctors to access, use and share knowledge and thus contribute to their ability to uphold the part of the Hippocratic Oath concerned with respecting 'the hard-won scientific gains of those physicians in whose steps I walk' and sharing 'such knowledge as is mine with those who are to follow'. How technology supports connections between doctors and knowledge is considered by focusing on the use of mobile technology in the workplace and Web 2.0 tools. Methods Sfard's 'acquisition' and 'participation' models are employed to help develop an understanding of what these uses of technology mean for learning and knowledge sharing. Discussion The employment of technology is not neutral in its effects. Issues relate to knowledge ownership, information overload, quality control and interpretations attached to the use of mobile devices in the workplace. These issues raise deeper questions about the nature of knowledge and social theory and socio-material research questions about the effect of technology on workplace learning. Conclusion Although the empirical and theoretical evidence presented shows how technology has clear potential to contribute both to accessing evidence and sharing knowledge, there is need for further research that applies theoretical frameworks to the analysis of the impact of technology on workplace learning. [ABSTRACT FROM AUTHOR]

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

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

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

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

Medical Education 2012: 46: 748-756 Context Capacity-building programmes in low-income countries (LICs) are subject to a tension between the requirement to best train workers to fulfil national needs and the requirement to meet international expectations of their students, academics and institutions. This paper presents a theoretical framework developed from a case study of an undergraduate degree programme in Malawi and explores how national needs and international expectations can be managed in health profession settings in LICs to ensure successful curriculum development. Methods An inductive qualitative methodology, grounded theory, combined with open-ended interviews with students, graduates, tutors and external stakeholders in the programme, was used to develop a theoretical framework. Results A total of 22 interviews were performed; their analysis conceptualised the tension between national needs and international expectations, and resulted in 12 codes, in four categories: competing and advancing agendas; processes of collaboration; developing a programme or professional identity, and perceptions of programme change. Conclusions This study describes a conceptual framework highlighting three particular areas for analysis to aid in understanding how to best manage competing agendas. These areas refer to, respectively, the significance of international expectations, the organisational climate, and the development of a professional identity. [ABSTRACT FROM AUTHOR]

Context: Interprofessional practice is required to manage complex health care needs globally. It is well established that interprofessional placements (IPP) prepare students to work collaboratively, yet IPP implementation remains limited and disjointed. Objectives: This review synthesised student, educator and service user perspectives in order to better understand challenges of IPP and provide recommendations for sustainable IPP implementation. Methods: A systematic metasynthesis of qualitative literature sourced from databases including CINAHL, Embase and PsycINFO was completed. Studies that incorporated student, educator and/or service user perspectives on IPP experiences were included. We focused specifically on factors limiting implementation of IPP. The presage‐process‐product (3P) theory provided the theoretical framework for inductive synthesis of 41 empirical studies. A confidence rating for findings was formulated using CERQual (confidence in evidence from reviews of qualitative research). Results: We developed three themes, which represent key challenges to IPP becoming embedded in placement culture: (i) thin theoretical foundations underpinned IPP, limiting understanding of the learning processes involved; (ii) implementation relied heavily on individual champions, which curtails investment and sustainability when personnel change, and (iii) students, educators and service users were unsure of the function of IPP and their respective roles, leading to uncertainty along with some negative perceptions of this placement approach. Conclusions: In line with the 3P theoretical framework, IPP would benefit from explicit connections with educational and change management theories during presage stage IPP requires coordinated leadership and resource investment, and during product stage clear integration of interprofessional learning outcomes in curricula is advised. Addressing the identified challenges across the stages of IPP will support further development of IPP, firmly establishing this approach within placement culture. IPP can them make a significant contribution to the development of a collaborative practice‐ready workforce. This in turn will enhance service user outcomes and safety. This review provides an overview of the challenges faced during interprofessional placements and makes recommendations for facilitating collaborative practice to address increasingly complex healthcare needs. [ABSTRACT FROM AUTHOR]

Medical Education 2011: 45: 995-1005 Context A particularly onerous aspect of the transition from medical student to practising doctor concerns the necessity to be able to rapidly identify acutely unwell patients and initiate appropriate resuscitation. These are skills in which many graduates feel poorly prepared and are considered by some to be best learned on the job. This constructivist study investigated the factors that influence the behaviour of junior doctors in this context and initiated the development of a framework that promotes understanding of this important area. Methods Focus groups involving 36 clinicians with a variety of clinical experience were conducted and analysed using a qualitative, grounded theory approach. The complex relationships between emergent themes guided the development of a framework that was refined and validated by further interviews with participants. Results Six main themes, grouped under three broad headings, emerged from the data: 'transferring knowledge into practice' and 'decision making and uncertainty' (cognitive challenges); 'acts and omissions' and 'identity and expectations' (roles and responsibilities), and, finally, 'the medical hierarchy' and 'performing under stress' (environmental factors). The framework presented within this paper illustrates the complex relationships between these factors. Conclusions Although the potential of metacognitive strategies to reduce medical error is acknowledged, the framework promotes looking beyond the individual to consider the contributions to patient safety of identity issues, role uncertainty and the hierarchical clinical environment. A more distributed approach to situation awareness may help junior doctors to better tolerate complexity and uncertainty. The efficacy of simulation as an educational strategy may be improved by finding ways to recreate the hierarchical and stressful environment in which junior doctors practise. Junior doctors should be aware of the impact of affect and emotion on behaviour, and clinical supervisors should strive to ensure that roles and responsibilities are explicitly discussed. [ABSTRACT FROM AUTHOR]

Medical Education 2011: : 471-477 Interprofessional education (IPE) has been gaining traction in post-secondary institutions. Many schools introduce IPE early to their health professional students, often in the context of a large-scale event in Year 1. This paper presents findings from a study undertaken by a medical student (a classmate of the research participants) and details Year 1 students' initial perceptions of IPE. Using an exploratory case study approach, eight focus groups of medical, pharmacy, dental, occupational therapy and social work students were gathered over 2 years (2007 and 2008). All participants had attended an IPE event delivered to nearly 1200 students each year. All data were analysed using an inductive thematic approach. The data indicated that, although students were generally positive towards IPE, many expressed dissatisfaction with the way their initial IPE event had been implemented. In particular, students felt that delivering IPE as a large-scale activity limited the amount of meaningful interprofessional interaction that could be achieved. A number of students also expressed concern about the 'artificial' nature of some of their interprofessional activities, which again limited their value. Students went on to offer various suggestions to improve their first exposure to IPE. Our findings reinforce the notion that students value IPE, but offer some new insights into how introductory IPE programming might be organised. Although large-scale activities can provide IPE activities to a wide range of students, which is advantageous from a specifically administrative perspective, students' opinions reveal that this form of IPE involves a number of challenges in their initial engagement with concepts of interprofessional teamwork and collaboration. [ABSTRACT FROM AUTHOR]

Medical Education 2010: 44: 1095-1104 Objectives Comprehensive programme evaluation frameworks are increasingly important to inform the development of sophisticated programmes that educate the next generation of health professions education researchers. This paper highlights an innovative process undertaken by the Wilson Centre for Research in Education to evaluate its fellowship programme. This process incorporates the principles of programme theory and a framework drawn from the field of organisational development. Methods During the iterative and dynamic process of articulating the programme's theory, a hidden tension between structured and unstructured components of the fellowship programme was unearthed. This necessitated a secondary process beyond traditional programme evaluations involving the use of a method called 'Polarity Management®'. Results The use of this model allowed the team to identify priority actions for balancing both the structured and unstructured components, along with indicators which can serve as an early warning system to alert observers to any imbalance between the components. Discussion Lessons learned and implications for other health education programming and the practice of programme evaluation are discussed. [ABSTRACT FROM AUTHOR]

Introduction: Health professional identity transitions involve a dynamic period of liminality prompting a time of considerable uncertainty and self‐doubt. For postgraduate trainees in the United Kingdom, the transition to medical registrar can be a significant deterrent to recruitment and retention. Narrative analysis offers insight into identity work during transitions with potential to inform strategies for developing professional identities. This study aimed to use narrative analysis to explore trainees' experiences and their sense of agency during the liminal phase of this transition. Methods: Following ethical approval, internal medicine (IM) trainees in their second year of IM training were interviewed. Transcripts were audio recorded, transcribed verbatim and analysed to identify narratives describing liminality during the transition to the role of medical registrar, including examples of rejecting and claiming identity grants. Narrative analysis, as described by Riessman and influenced by James Gee's units of discourse, was undertaken, with an agentive lens applied to the data. Results: Between January 2021 and February 2022, 19 IM trainees were interviewed. Given the in‐depth analysis, four narratives were purposively selected to present, including trainees rejecting and claiming the medical registrar role. Trainees tended to describe negative experiences, but those with a higher sense of agency demonstrated positive reflection and identity construction through narrative. There was often identity dissonance between how trainees defined their stage in the transition to medical registrar and how their narrative illustrated their identity work. Conclusion: This study exemplifies narrative analysis' linguistic and agentive lenses in exploring the experience of the liminal identity transitional period. The findings reflect the identity dissonance experienced by trainees during this time and sheds light on their sense of agency throughout. It heralds a need to acknowledge the significant liminality experienced during transitions throughout medical training and to empower a sense of agency to support identity work. The authors' narrative analysis reveals identity dissonance experienced by trainees, as they transition to medical registrar, in ways that herald need to empower a sense of agency to support identity work. [ABSTRACT FROM AUTHOR]

Background: Substantial numbers of medical students and doctors have specific learning difficulties (SpLDs) and failure to accommodate their needs can disadvantage them academically. Evidence about how SpLDs affect performance during postgraduate general practice (GP) specialty training across the different licencing assessments is lacking. We aimed to investigate the performance of doctors with SpLDs across the range of licencing assessments. Methods: We adopted the social model of disability as a conceptual framework arguing that problems of disability are societal and that barriers that restrict life choices for people with disabilities need to be addressed. We used a longitudinal design linking Multi‐Specialty Assessment (MSRA) records from 2016 and 2017 with their Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA), Recorded Consultation Assessment (RCA) and Workplace Based Assessment (WPBA) outcomes up to 2021. Multivariable logistic regression models accounting for prior attainment and demographics were used to determine the SpLD doctors' likelihood of passing licencing assessments. Results: The sample included 2070 doctors, with 214 (10.34%) declaring a SpLD. Candidates declaring a SpLD were significantly less likely to pass the CSA (OR 0.43, 95% CI 0.26, 0.71, p = 0.001) but not the AKT (OR 0.96, 95% CI 0.44, 2.09, p = 0.913) or RCA (OR 0.81, 95% CI 0.35, 1.85, p = 0.615). Importantly, they were significantly more likely to have difficulties with WPBA (OR 0.28, 95% CI 0.20, 0.40, p < 0.001). When looking at licencing tests subdomains, doctors with SpLD performed significantly less well on the CSA Interpersonal Skills (B = −0.70, 95% CI −1.2, −0.19, p = 0.007) and the RCA Clinical Management Skills (B = −1.68, 95% CI −3.24, −0.13, p = 0.034). Conclusions: Candidates with SpLDs encounter difficulties in multiple domains of the licencing tests and during their training. More adjustments tailored to their needs should be put in place for the applied clinical skills tests and during their training. Botan et al. show that candidates with specific learning difficulties can encounter challenges in multiple domains during licensing and GP training, outlining how adjustments need tailored to their needs. [ABSTRACT FROM AUTHOR]

Introduction: While expert clinical practice requires a flexible approach to problem solving, evidence shows that medical clerks tend to focus on knowledge acquisition as the key to expertise. It is not until residency training that learners shift their understanding of expertise towards developing adaptive approaches to clinical problems. This raises the possibility that adaptive expertise is a threshold concept and that authentic clinical experiences involving complex problem solving are required to create the liminal state that enables transformation to an adaptive expertise mindset. With this possibility in mind, the current study examined the conceptualisations of expertise held by recently graduated physical therapists using the framework of threshold concepts as a sensitising lens. Methods: An exploratory qualitative study in the Constructivist Grounded Theory tradition was conducted, utilising 14 one‐on‐one semi‐structured interviews with recently graduated physical therapists. Results: Most participants were in a transitional state regarding their conceptualisation of expertise, sometimes focusing on the acquisition of knowledge and routinisation of practice as their hallmark of expertise and at other times acknowledging the need for developing more dynamic and adaptive problem‐solving approaches to patient care. These mixed responses were expressed not only in their framing of patient management but also in their reasons for valuing colleagues and in their approach to continuing professional development. Notably, many participants suggested that the interview itself was a key impetus to their reflecting on these issues. Conclusion: Our findings suggest that participants were only beginning to transition into an adaptive expertise mindset upon entering practice, reinforcing the possibility that authentic practice may be an important impetus for recognising the limits of routine expertise. However, spontaneous comments from participants suggest that this transition might be better supported though active guided reflection in addition to meaningful clinical engagement with patients and colleagues. After interviewing physical therapy students, the authors suggest that adaptive expertise is a threshold concept that requires the "troublesome" discovery of the limits of "knowing all the answers." [ABSTRACT FROM AUTHOR]

Background: Virtual interprofessional education (IPE) has emerged as a promising alternative to traditional in‐person IPE. However, theoretical frameworks to support virtual interprofessional learning are not well established. Two theoretical frameworks emerged as relevant to virtual IPE: (1) the Canadian Interprofessional Health Collaborative (CIHC) interprofessional learning framework and (2) Dornan's Experience‐Based Learning Model (ExBL) of workplace learning. In this study, we sought to explore virtual IPE using both frameworks to develop new theoretical understandings and identify assumptions, gaps and barriers. Methods: This was a qualitative study. Semi‐structured interviews were conducted with medical and nursing student participants (n = 14) and facilitators (n = 3) from virtual IPE workshops. Transcripts were analysed using directed content analysis methodology, informed by the CIHC and ExBL frameworks. Themes were explored using mind‐mapping transitional coding. Data collection and analysis were continued iteratively until themes with adequate conceptual depth, relevance and plausibility were identified. Results: Three themes were identified: (1) a shift in the balance of personal and professional, (2) blunted sociologic fidelity and (3) uncertainty and threats to interpersonal connections. Professional distinctions and hierarchies are blurred virtually. This contributed to an increased sense of psychological safety among most learners and lowered the threshold for participation. Separation from workplace sociologic complexity facilitated communication and role clarification objectives. However, loss of immersion may limit deeper engagement. Interprofessional objectives that rely on deeper sociological fidelity, such as conflict resolution, may be threatened. Informal interactions between learners are hindered, which may threaten organic development of interprofessional relationships. Conclusions: Role clarification and communication objectives are preserved in virtual IPE. Educators should pay close attention to psychological safety and sociologic fidelity—both to leverage advantages and guard against threats to connection and transferability. Virtual IPE may be well suited as a primer to in‐person activities or as scaffolding towards interprofessional workplace practice. Although virtual environments have the potential to increase psychological safety and blur professional distinctions, such factors require care when planning virtual interprofessional education activities. [ABSTRACT FROM AUTHOR]

Introduction: Medical students' longitudinal care of patients supports clinical learning and promotes patient‐centredness. The literature presents little empirically derived guidance for faculty to facilitate students' longitudinal learning and care. Informed by the conceptual framework of relational learning, this study investigated faculty perspectives about longitudinal teaching, their strategies for facilitating students' longitudinal learning and perceived barriers and enablers. Methods: Using a convergent mixed‐methods approach at a single academic medical centre, the authors conducted a survey and two focus groups in 2018–2019 with faculty members teaching in three longitudinal clinical courses. Quantitative analyses included descriptive statistics and chi‐square tests. Qualitative content analysis described deductive categories and identified inductive themes. Results: Forty‐three eligible faculty (69%) completed the survey. Ninety‐one percent (n = 39) reported that teaching in a longitudinal model enhanced their experience as preceptors. Faculty described activities students performed to provide longitudinal care: spending time with patients independently (n = 38, 88%), making follow‐up phone calls (n = 35; 81%) and participating in home‐ and community‐based visits (n = 20, 47%), among others. Twelve faculty participated in two focus groups. Deductive analysis characterised strategies for facilitating students' longitudinal learning and barriers and enablers. Strategies included "encouraging students to follow patients," "faculty adaptability," "offering guidance and setting expectations," and "careful patient selection." Barriers included scheduling limitations, and enablers included student initiative. Inductive analysis identified two themes: faculty goals for students and faculty benefits from teaching. Goals included meaningful engagement with patients and their illness over time. Benefits from teaching included personal gratification, mentorship, and holistic student assessment. Discussion: Our survey and focus group findings demonstrated positive faculty attitudes and experiences, characterised faculty goals and approaches, and identified elements of the educational context that hindered or facilitated longitudinal teaching and learning. This study's faculty perspectives build upon prior investigations of students' and patients' perspectives, offer teaching strategies, and may guide faculty development. This mixed‐methods study identified goals, strategies, barriers and enablers of longitudinal learning and caregiving. Findings are situated within the framework of relational learning and can inform faculty development. [ABSTRACT FROM AUTHOR]

Context There have been repeated calls for the greater use of conceptual frameworks and of theory in medical education. Although it is familiar to few medical educators, Michel Foucault's work is a helpful theoretical and methodological source. Methods This article explores what it means to use a 'Foucauldian approach', presents a sample of Foucault's historical-genealogical studies that are relevant to medical education, and introduces the work of four researchers currently undertaking Foucauldian-inspired medical education research. Results Although they are not without controversy, Foucauldian approaches are employed by an increasing number of scholars and are helpful in shedding light on what it is possible to think, say and be in medical education. Conclusions Our hope in sharing this Foucauldian work and perspective is that we might stimulate a dialogue that is forward-looking and optimistic about the possibilities for change in medical education. [ABSTRACT FROM AUTHOR]