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The centrality of entrustable professional activities (EPAs) in competency-based medical education (CBME) is predicated on the assumption that low-stakes, high-frequency workplace-based assessments used in a programmatic approach will result in accurate and defensible judgments of competence. While there have been conversations in the literature regarding the potential of this approach, only recently has the conversation begun to explore the actual experiences of clinical faculty in this process. The purpose of this qualitative study was to explore the process of EPA assessment for faculty in everyday practice. We conducted 18 semi-structured interviews with Anesthesia faculty at a Canadian academic center. Participants were asked to describe how they engage in EPA assessment in daily practice and the factors they considered. Interviews were audio-recorded, transcribed, and analysed using the constant comparative method of grounded theory. Participants in this study perceived two sources of tension in the EPA assessment process that influenced their scoring on official forms: the potential constraints of the assessment forms and the potential consequences of their assessment outcome. This was particularly salient in circumstances of uncertainty regarding the learner's level of competence. Ultimately, EPA assessment in CBME may be experienced as higher-stakes by faculty than officially recognized due to these tensions, suggesting a layer of discomfort and burden in the process that may potentially interfere with the goal of assessment for learning. Acknowledging and understanding the nature of this burden and identifying strategies to mitigate it are critical to achieving the assessment goals of CBME.

Heath advocacy (HA) remains a difficult competency to train and assess, in part because practicing physicians and learners carry uncertainty about what HA means and we are missing patients' perspectives about the role HA plays in their care. Visual methods are useful tools for exploring nebulous topics in health professions education; using these participatory approaches with physicians and patients might counteract the identified training challenges around HA and more importantly, remedy the exclusion of patient perspectives. In this paper we share the verbal and visual reflections of patients and physicians regarding their conceptualizations of, and engagement in 'everyday' advocacy. In doing so, we reveal some of HA's hidden dimensions and what their images uncovered about the role of advocacy in patient care. Constructivist grounded theory guided data collection and analysis. Data was collected through semi-structured interviews and photo-elicitation, a visual research method that uses participant generated photographs to elicit participants knowledge and experiences around a particular topic. We invited patients living with chronic health conditions (n = 10) and physicians from diverse medical and surgical specialties (n = 14) to self-select photographs representing their experiences navigating HA in their personal and professional lives. Both groups found taking photographs useful for revealing the nuanced and circumstantial factors that either enabled or challenged their engagement in HA. While patients' photos highlighted their embodiment of HA, physicians' photos depicted HA as something quite elusive or as a complicated and daunting task. Photo-elicitation was a powerful tool in eliciting a diversity of perspectives that exist around the HA role and the work advocates perform; training programs might consider using visuals to augment teaching for this challenging competency.

While undesirable, unexpected disruptions offer unique opportunities to enact adaptive expertise. For adaptive expertise to flourish, individuals and teams must embrace both efficiency and adaptation. While some industries do it readily, others continue to struggle with the tension between efficiency and adaptation, particularly when otherwise stable situations are unexpectedly disrupted. For instance, in healthcare settings, the efficiency mandate for strict compliance with scopes of practice can deter teams from using the adaptive strategy of making their members interchangeable. Yet, interchangeability has been hinted as a key capacity of today' teams that are required to navigate fluid team structures. Because interchangeability -- as an adaptive strategy -- can generate antagonistic reactions, it has not been well studied in fluid teams. Thus, in this exploratory qualitative study we sought to gain insights into how interchangeability manifests when fluid teams from five different contexts (healthcare, emergency services, orchestras, military, and business) deal with disruptive events. According to our participants, successful interchangeability was possible when people knew how to work within one's role while being aware of their teammates' roles. However, interchangeability included more than just role switching. Interchangeability took various forms and was most successful when teams capitalized on the procedural, emotional, and social dimensions of their work. To reflect this added complexity, we refer to interchangeability in fluid teams as Ecological Interchangeability. We suggest that ecological interchangeability may become a desired feature in the training of adaptive expertise in teams, if its underlying properties and enabling mechanisms are more fully understood.

In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.

In both clinical and health professions education research, rich pictures, or participant-generated drawings of complex phenomena, are gaining recognition as a useful method for exploring multifaceted and emotional topics in medicine. For instance, two recent studies used rich pictures to augment semi-structured interviews exploring trainees', health care professionals' (HCPs), and parents' experiences of difficult conversations in the Neonatal Intensive Care Unit (NICU)--an environment in which communication is often challenging, anxiety-provoking, and emotionally distressing. In both studies, participants were invited to draw a picture depicting how they experienced a difficult conversation in this setting. As part of the interview process, participants were asked to both describe how they engaged with rich pictures, and to share their perceptions about the affordances and limitations of this research method. Here, their perspectives are reported and the possibilities of using rich pictures to inform pedagogical innovations in health professions education and research are considered.

Surgeons practice their own variations on a procedure. Residents experience shifting thresholds between variations that one surgeon holds firmly as principle and another takes more lightly as preference. Such variability has implications for surgical education, but the impact is not well understood. This is a critical problem to investigate as programs seek to define procedures for competency-based medical education (CBME) and improve learning through deliberate practice. Our study analyzes the emergence of procedural variation in an early-adopter CBME program through a situational analysis of tonsillectomy, a foundation level procedure in this otolaryngology, head and neck surgical program. An earlier phase of the study identified frequent variations (n = 12) on tonsillectomy among co-located surgeons who routinely perform this procedure (n = 6). In the phase reported here we interviewed these surgeons (n = 4) and residents at different stages of training (n = 3) about their experiences of these variations to map the relations of contributing social and material actors. Our results show that even a basic procedure resists standardization. This study contributes a sociomaterial grounded theory of surgical practice as an embodied response to conditions materialized by intra-relations of human and more-than-human actors. Shifting root metaphors about practice in surgical education from standardization to stabilization can help residents achieve stable-for-now embodiments of performance as their practice thresholds continue to emerge.

AbstractContrary to common belief, effective communication is not only achieved via verbal exchanges of information. It requires a thoughtful combination of verbal and non-verbal cues since, in some circumstances, verbal communication in healthcare may be impossible, unfavourable or ineffective. The semiotics literature suggests that effective non-verbal communication goes beyond body language and gestures. It also includes the use of objects (i.e. traces) to transmit a message. We call this trace-based communication (TBC). In this perspective paper, we offer some reflections from our experience researching and using trace-based communication for training purposes. Our intention was to bring further awareness to the opportunities that trace-based communication might enable, including opportunities to enhance trainee-supervisor interactions, and consequently inform curriculum design. [ABSTRACT FROM AUTHOR]

Learner engagement matters, particularly in simulation-based education. Indeed, it has been argued that instructional design only matters in the service of engaging learners in a simulation encounter. Yet despite its purported importance, our understanding of what engagement is, how to define it, how to measure it, and how to assess it is limited. The current study presents the results of a critical narrative review of literature outside of health sciences education, with the aim of summarizing existing knowledge in these areas and providing a research agenda to guide future scholarship on learner engagement in healthcare simulation. Building on this existing knowledge base, we provide a working definition for engagement and provide an outline for future research programs that will help us better understand how health professions' learners experience engagement in the simulated setting. With this in hand, additional research questions can be addressed including: how do simulation instructional design features (fidelity, range of task difficulty, feedback, etc.) affect engagement? What is the relationship between engagement and simulation learning outcomes? And how is engagement related to or distinct from related variables like cognitive load, motivation, and self-regulated learning?

Phenomenon: Interprofessional healthcare team (IHT) collaboration can produce powerful clinical benefits for patients; however, these benefits are difficult to harness when IHTs work in stressful contexts. Research about stress in healthcare typically examines stress as an individual psychological phenomenon, but stress is not only a person-centered experience. Team stress also affects the team's performance. Unfortunately, research into team stress is limited and scattered across many disciplines. We cannot prepare future healthcare professionals to work as part of IHTs in high-stress environments (e.g., emergency medicine, disaster response) unless we review how this dispersed literature is relevant to medical education. Approach: The authors conducted a narrative review of the literature on team stress experienced by interprofessional teams. The team searched five databases between 1 Jan 1990 and 16 August 2021 using the search terms: teams AND stress AND performance. Guided by four research questions, the authors reviewed and abstracted data from the 22 relevant manuscripts. Findings: Challenging problems, time pressure, life threats, environmental distractors, and communication issues are the stressors that the literature reports that teams faced. Teams reacted to team stress with engagement/cohesion and communication/coordination. Stressors impact team stress by either hindering or improving team performance. Critical thinking/decision-making, team behaviors, and time for task completion were the areas of performance affected by team stress. High-quality communication, non-technical skills training, and shared mental models were identified as performance safeguards for teams experiencing team stress. Insights: The review findings adjust current models explaining drivers of efficient and effective teams within the context of interprofessional teams. By understanding how team stress impacts teams, we can better prepare healthcare professionals to work in IHTs to meet the demands placed on them by the ever-increasing rate of high-stress medical situations. [ABSTRACT FROM AUTHOR]

In recent years, hospitals have experienced alarming increases in admissions of people who inject drugs (PWID), which present unique challenges to the care process. Untangling the complexity of care can be difficult due to interactions that occur between human and non-human elements including hospital systems, policy, technology, time, and space. The purpose of this study was to explore relations between social and material elements within the acute care environment, to better understand how care is enacted and to identify novel approaches for improvement. Data collection and analysis utilized a practice-based approach informed by constructivist grounded theory and sociomaterial perspectives, which emphasized relationships between human and non-human elements. Data included observational field notes, interviews, and artifacts from 154 hours spent on acute medicine units of two hospitals in an urban setting in Ontario, Canada. Findings revealed that differing expectations, strained conversations, and various policies assembled to produce misalignments in care. Such misalignments included mistrust, suboptimal pain and withdrawal management, and frequent patient absences and/or discharge against medical advice. Care misaligned in ways that reflected both social and material elements, demonstrating a need for hospital staff and systems to challenge existing care models built around individual control and abstinence-informed practices. [ABSTRACT FROM AUTHOR]

Introduction: To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. Methods: We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5‐hour session involving a rich picture drawing and one‐on‐one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. Results: We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre‐existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. Conclusion: This study uncovers an ideology that shapes residents' developing professional identity—an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements. How does ideology impact residents' identity struggle during training? This study delves into the complexities. Ideological pressures like perfectionism, conflicting personal identities, and mismatched professional ideals create challenges. Recognizing and reshaping these ideologies can aid in healthier identity development. [ABSTRACT FROM AUTHOR]