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Purpose: Care of complex patients requires collaboration across hospital and community settings. Yet there is little recognition of the capabilities that healthcare workers need to effectively implement integrated care. An adaptive expertise theoretical framework can inform educational efforts that aim to give providers the abilities to navigate complexity and ambiguity in the healthcare system, including across hospital and community settings. Prior education research in the HIV sector has demonstrated that adaptive expert skills can be cultivated through education that emphasizes perspective exchange, inviting uncertainty in practice and integration of diverse perspectives on care. Design/methodology/approach: These principles informed the creation of an Extension for Community Healthcare Outcomes (ECHO) in HIV Psychiatry – the first ECHO directed at a non-clinical, community health worker (CHW) audience. The goal was to improve informal collaborations across hospitals and communities. Findings: Participation in the ECHO was robust, with significant on-camera engagement. Participants attributed success of the ECHO to key themes: explicit value placed on all kinds of knowledge (not simply clinical knowledge), emphasis on approaches for navigating ambiguity and complexity and engagement in perspective exchange for provision of integrated, team-based care. Future cycles of ECHO HIV Psychiatry are being pursued, with a focus on the development of adaptive expert capabilities and the impact on integration of care between community and hospital services. Originality/value: To our knowledge, this is the only ECHO that is specifically aimed at frontline CHWs. [ABSTRACT FROM AUTHOR]

Current models of care delivery are failing patients with complexity, like those living with HIV, mental illness and other psychosocial challenges. These patients often require resource-intensive personalized care across hospital and community settings, but available supports can be fragmented and challenging to access and navigate. To improve this, the authors created a program to enhance integrated, trauma-informed care through an innovative educational role for a HIV community caseworker embedded in an academic HIV Psychiatry clinic, called the Mental Health Clinical Fellowship. Through qualitative interviews with 21 participants (patients, physicians, clinicians and Mental Health Clinical Fellows) from October 2020–March 2023, the authors explore how implementation of this program affects patient experiences and satisfaction with care. Patients described their care experiences as less stigmatizing, more accessible, holistic and coordinated. They often attributed this to the integration between fellow and psychiatrist, and specifically the accessible stance of community organizations embedded within a hospital, which helped build trust. Interchangeable and integrated support by caseworker and psychiatrist improved patient engagement in psychiatric management and patient satisfaction with their care. Cross-context and cross-disciplinary care provision that includes providers from community and hospital working directly together to deliver care can improve care for patients with significant complexity. [ABSTRACT FROM AUTHOR]

Importance: Despite mounting evidence for the management of various health care conditions, the uptake of scientific evidence in occupational therapy is often suboptimal. Although positive attitudes and self-efficacy are key to evidence-based practices (EBPs), how one becomes an evidence-based practitioner, and how expertise in EBP manifests in practice, remains unclear. Objective: To describe how expert evidence-based practitioners conceptualize and enact their expertise in stroke rehabilitation. Design: Qualitative interpretive descriptive study using in-depth semistructured interviews with eight occupational therapists identified as expert evidence-based practitioners in a previous study. Transcripts were analyzed using an inductive thematic content analysis, and emergent themes were identified. Settings: Rehabilitation settings across Canada. Results: Six overarching themes emerged: (1) relying on personal attributes to engage in practice improvement, (2) acting on factors that motivate and trigger EBP, (3) achieving better outcomes because of engagement in EBP, (4) using an adaptive decision-making process, (5) participating in professional activities that contribute to practice improvement, and (6) working in a practice area with a large body of evidence. Conclusions and Relevance: Expertise in stroke rehabilitation EBP appears to be a function of several personal attributes and habits of mind in addition to being influenced by a commitment to client-centered practice. Expertise requires a combination of deliberate effort and motivation to improve client outcomes, always in a context conducive to reflection, adaptation, and openness to innovation. Experts who model these traits and articulate the processes used to develop their expertise can be viewed as promising educational and continuing professional development resources. What This Article Adds: Expert evidence-based occupational therapists develop their expertise in this domain through commitment to client-centered practice, efforts toward honing this aspect of practice, and a willingness to innovate and adapt to challenging situations. Although positive attitudes and self-efficacy are key to evidence-based practices (EBPs), how one becomes an evidence-based practitioner, and how expertise in EBP manifests in practice, remains unclear. This article describes how expert evidence-based occupational therapists develop their expertise. [ABSTRACT FROM AUTHOR]

Introduction: The use of data to inform lifelong learning has become increasingly important in continuing professional development (CPD) practice. Despite the potential benefits of data-driven learning, our understanding of how physicians engage in data-informed learning activities, particularly for CPD, remains unclear and warrants further study. The purpose of this study was to explore how physicians perceive cultural factors (individual, organizational, and systemic) that influence the use of clinical data to inform lifelong learning and self-initiated CPD activities. Methods: This qualitative study is part of an explanatory sequential mixed-methods study examining data-informed learning. Participants were psychiatrists and general surgeons from Canada and the United States. Recruitment occurred between April 2019 and November 2019, and the authors conducted semistructured telephone interviews between May 2019 and November 2019. The authors performed thematic analysis using an iterative, inductive method of constant comparative analysis. Results: The authors interviewed 28 physicians: 17 psychiatrists (61%) and 11 general surgeons (39%). Three major themes emerged from the continuous, iterative analysis of interview transcripts: (1) a strong relationship between data and trust, (2) a team-based approach to data-informed learning for practice improvement, and (3) a need for organizational support and advocacy to put data into practice. Conclusion: Building trust, taking a team-based approach, and engaging multiple stakeholders, such as data specialists and organizational leadership, may significantly improve the use of data-informed learning. The results are situated in the existing literature, and opportunities for future research are summarized. [ABSTRACT FROM AUTHOR]

Introduction: Despite the support for and benefits of data-driven learning, physician engagement is variable. This study explores systemic influences of physician use of data for performance improvement in continuing professional development (CPD) by analyzing and interpreting data sources from organizational and institutional documents. Methods: The document analysis is the third phase of a mixed-methods explanatory sequential study examining cultural factors that influence data-informed learning. A gray literature search was conducted for organizations both in Canada and the United States. The analysis contains nonparticipant observations from professional learning bodies and medical specialty organizations with established roles within the CPD community known to lead and influence change in CPD. Results: Sixty-two documents were collected from 20 Canadian and American organizations. The content analysis identified the following: (1) a need to advocate for data-informed self-assessment and team-based learning strategies; (2) privacy and confidentiality concerns intersect at the point of patient data collection and physician-generated outcomes and need to be acknowledged; (3) a nuanced data strategy approach for each medical specialty is needed. Discussion: This analysis broadens our understanding of system-level factors that influence the extent to which health information custodians and physicians are motivated to engage with data for learning. [ABSTRACT FROM AUTHOR]

Medical school curricula require regular updating. We adopted an activity theory lens to conduct a holistic, multiple stakeholder-informed analysis of curricular reform, aiming to understand how the social relations between groups contribute to unanticipated tensions and outcomes. A research assistant conducted semi-structured interviews with purposively sampled (N = 19) administrative staff, faculty course leads, faculty tutors, curriculum developers, change leaders and student leaders. The team applied a framework analysis to guide within and between stakeholder comparisons. Participants reported unique (N = 21) and cross-cutting (N = 17) contradictions underscoring emerging drivers of current and potential change. Unique contradictions raised by 1–2 groups represented seeds of change that had the potential to spread across all groups. By contrast, two general types of cross-cutting contradictions arose when one group had a dominant, confirming voice or two or more groups had contrasting perspectives. While finding contradictions was expected, our analysis profiled their nature and some of the specific tensions they raised across and within stakeholder groups. The activity theory lens provided an accessible way to unravel curricular reform into manageable units of analysis. Systematically identifying contradictions arising from curricular reform will help stakeholders collaborate with a shared purpose toward positive, sustained change. [ABSTRACT FROM AUTHOR]

While there is increasing effort among medical schools to recruit diverse students, there is a paucity of research into the unique experiences of these students during their transition to medicine. This study explored how experiences during medical school orientation influence students' transition into the medical profession. Semi-structured interviews were conducted (April-August 2019) with 16 first-year Canadian medical students. We applied descriptive thematic analysis using a constant comparative approach. Verbatim transcripts were coded and analyzed to elucidate themes. Participants highlighted the importance of social orientation during their transition into medical school and noted experiencing complex social pressures during this time. They shared how incoming students were introduced to the dominant medical professional identity during orientation. Participants noted tensions during this period, many of which revolved around the dominant identity and their past, present and future selves. Longstanding issues of diversity and inclusion in medicine manifest from day one of medical school. While orientation may be intended as a transition period to welcome students into the profession, it is a crucial period for medical schools to intentionally establish a commitment to an inclusive culture. Waiting to do so after identity formation has already begun is a missed opportunity. [ABSTRACT FROM AUTHOR]

Phenomenon: Despite the emergence of the integrated care (IC) model, IC is variably taught and is challenged by current siloed competency domains. This study aimed to define IC competencies spanning multiple competency domains. Approach: Iterative facilitated discussions were conducted at a half-day education retreat with 25 key informants including clinician educators and education scientists. Seven one-on-one semistructured interviews were subsequently conducted with different interprofessional providers in IC settings within a Canadian context. Data collection grounded in patient cases with a physical illness and concurrent mental illness (medical psychiatry) were used to elicit identification of complex patient needs and the key medical psychiatry knowledge and skills required to address these needs. A thematic analysis of transcripts was performed using constant comparison to iteratively identify themes. Findings: Participants described 4 broad competency domains necessary for expertise in IC: (a) extensive integrated knowledge of biopsychosocial aspects of disease, systems of care, and social determinants of care; (b) skills to establish a longitudinal alliance with the patient and functional relationships with colleagues; (c) constructing a comprehensive understanding of individual patients' complex needs and how these can be met within their health and social systems; and (d) the ability to effectively meet the patient's needs using IC models. These 4 domains were linked by an overarching philosophy of care encompassing key enabling attitudes such as proactively pursuing depth to understand patient and system complexity while maintaining a patient-centered approach. Insights: The study addresses how development of IC expertise can be fostered by integration of individual IC competency domains. The findings align with previous research suggesting that competencies from existing frameworks are being enacted jointly in expert capabilities to meet the complex needs of patients, in this case with comorbid physical and mental health concerns. [ABSTRACT FROM AUTHOR]

Objectives: Direct observation is the foundation of assessment and learning in competency‐based medical education (CBME). Despite its importance, there is significant uncertainty about how to effectively implement frequent and high‐quality direct observation. This is particularly true in specialties where observation of non‐procedural skills is highly valued and presents unique challenges. It is therefore important to understand perceptions of direct observation to ensure successful acceptance and implementation. In this study, we explored perceptions of direct observation in internal medicine. Methods: We interviewed internal medicine attending physicians (n = 9) and residents (n = 8) at the University of Toronto, purposively sampled for diversity. Using a constructivist grounded theory approach, constant comparative analysis was performed to develop a framework to understand perceptions of direct observation on the clinical teaching units. Results: Participants articulated a narrow perception of what constitutes direct observation, in contrast to their own descriptions of skills that were observed. This resulted in the perception that certain valuable skills that participants felt were routinely observed were nonetheless not 'directly observable', such as clinical reasoning, observed through case presentations and patient care discussions. Differentiating direct observation from informal observation led to overestimation of the time and resource requirements needed to enhance direct observation, which contributed to scepticism and lack of engagement related to CBME implementation. Conclusions: In an internal medicine training programme, perceptions of what constitutes direct observation can lead to under‐recognition and hinder acceptance in workplace‐based assessment and learning. Our results suggest a reframing of 'direct observation' for residents and attending physicians, by explicitly identifying desired skills in non‐procedurally‐based specialties. These findings may help CBME‐based training programmes improve the process of direct observation, leading to enhanced assessment and learning. Gauthier et al. demonstrate that residents and faculty in internal medicine have narrow perceptions about direct observation that hinder its acceptance in clinical practice. [ABSTRACT FROM AUTHOR]

This article reports on research into the relationships that emerged between hospital-based and community-based interprofessional diabetes programs involved in inter-agency care. Using constructivist grounded theory methodology we interviewed a purposive theoretical sample of 21 clinicians and administrators from both types of programs. Emergent themes were identified through a process of constant comparative analysis. Initial boundaries were constructed based on contrasts in beliefs, practices and expertise. In response to bureaucratic and social pressures, boundaries were redefined in a way that created role uncertainty and disempowered community programs, ultimately preventing collaboration. We illustrate the dynamic and multi-dimensional nature of social and symbolic boundaries in inter-agency diabetes care and the tacit ways in which hospitals can maintain a power position at the expense of other actors in the field. As efforts continue in Canada and elsewhere to move knowledge and resources into community sectors, we highlight the importance of hospitals seeing beyond their own interests and adopting more altruistic models of inter-agency integration. [ABSTRACT FROM AUTHOR]

Context Closer clinical supervision has been increasingly promoted to improve patient care. However, the continuous bedside presence of supervisors may threaten the model of progressive independence traditionally associated with effective clinical training. Studies have shown favourable effects of closer supervision on trainees' learning, but have not paid specific attention to the learning processes involved. Methods We conducted a simulation-based study to explore the learning opportunities created during simulated resuscitation scenarios under different levels of supervision. Fifty-three residents completed a supervised scenario. Residents were randomised to one of three levels of supervision: telephone (distant); in-person after telephone consultation (immediately available), and in-person from the beginning of the simulation (direct). These interactions were converted into 234 pages of transcripts for analysis. We performed an inductive thematic analysis followed by a deductive analysis using situated learning theory as a theoretical framework. Results Learning opportunities created during simulated scenarios were identified as belonging to either of two categories, incidental and engineered opportunities. The themes resulting from this framework contributed to our understanding of trainees' contributions to patient care, supervisors' influences on patient care, and trainee-supervisor interactions. All forms of supervision offered trainees incidental opportunities for practice, although the nature of these contributions could be affected by the bedside presence of supervisors. Supervisors' involvement in patient care by telephone and in person was associated with a shift of responsibility for patient care, but represented, respectively, engineered and incidental opportunities for observation. In-person supervisor-trainee interactions added value to observation and created additional opportunities for incidental feedback and engineered practice. Conclusions The shift of responsibility for patient care occurred during both direct and distant supervision, and did not necessarily translate into a lack of opportunities for trainee participation and practice. [ABSTRACT FROM AUTHOR]

The development of standardized, valid, and reliable methods for assessment of students' practice competence continues to be a challenge for social work educators. In this study, the Objective Structured Clinical Examination (OSCE), originally used in medicine to assess performance through simulated interviews, was adapted for social work to include a reflective dialogue that focused on the ability to conceptualize practice. Participants included current MSW students, recent graduates, and experienced social workers. The study demonstrated promising reliability for the method and the rating tools developed. Correlations between performance and reflection scores demonstrated that they are related, yet different, aspects of competence. The method demonstrated construct validity in that it differentiated between social workers in training and experienced workers. [ABSTRACT FROM AUTHOR]

Background/Purpose: The unique expertise and contributions to teaching of patients with chronic diseases is increasingly recognized and valued in medical education. Specifically in rheumatology, patient educators (also referred as patients partners) programs have been developed and shown to be effective for MSK exam teaching. To our knowledge, this educational strategy has never been adapted to pediatrics. We believe adolescents with juvenile idiopathic arthritis (JIA) might benefit from participation in such educational programs. Since little is known about how teens with JIA could actively be engaged in medical education, the main aim of the study was to explore and develop a detailed understanding of their perspective about potential contributions as patient educators. Methods: Using a qualitative approach, nineteen individual semi-structured interviews were conducted with adolescents diagnosed with JIA. A purposeful critical case sampling was realized and participants were recruited at two tertiary pediatric hospitals. Consistent with qualitative research analysis, interviews were conducted until theme saturation. A thematic analysis of the transcripts was achieved using a constant comparative approach. In order to facilitate the data analysis, NVivo qualitative research software was utilized. Results: Motivational factors for teens' involvement and main barriers for engagement in patient partners programs were identified. Beyond teaching components of the pediatric musculoskeletal exam, adolescents brought to light other competencies, such as teaching of communication skills, which they valued as important elements to incorporate in the educational program. They also recognized their unique form of knowledge, referred as experiential knowledge, and expressed how it may complement the trainees' biomedical knowledge. Conclusion: Our work demonstrates that adolescents with juvenile idiopathic arthritis express a strong desire to be engaged as patient educators, manifest a clear understanding of what their potential contributions to the teaching might be and vocalize their desire to share with trainees their unique experiential knowledge. This study represents the first step toward the development of patient-centered arthritis educational programs actively and effectively involving teens with JIA as teachers in medical education. [ABSTRACT FROM AUTHOR]