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To this date, research on the interplay between organisational structure/managerial and organisational value/psychological elements which impact on educational quality is scarce and fragmented. As a consequence of a lack of knowledge in this area, institutions often address these elements in isolation, moving past integral approaches, which reinforce the organisations' quality culture. In order to examine interrelationships between context characteristics, work-related psychological attitudes of staff and enhancement practices, a path analysis was performed on data collected from academics with teaching coordination roles. The findings highlight the paramount importance of a 'human relation' value orientation; this orientation influences empowerment, commitment and communication satisfaction. Rational goal values and ownership are positively related to quality enhancement practices. It is advocated that institutional policies and strategies directed at educational quality enhancement should leave discretionary space for the availing of academics' expertise. Nurturing collaborative teaching/learning communities with explicit concern for morale, involvement and development, deserves further cultivation.

Lindsay Bank,1,2 Mariëlle Jippes,3 Jimmie Leppink,4 Albert JJA Scherpbier,4 Corry den Rooyen,5 Scheltus J van Luijk,6 Fedde Scheele1,2,7 1Department of Healthcare Education, OLVG Hospital, 2Faculty of Earth and Life Sciences, Athena Institute for Transdisciplinary Research, VU University, Amsterdam, 3Department of Plastic Surgery, Erasmus Medical Center, Rotterdam, 4Faculty of Health, Medicine and Life Sciences, School of Health Professions Education, Maastricht University, Maastricht, 5Movation BV, Maarssen, 6Department of Healthcare Education, Maastricht University Medical Center+, Maastricht, 7School of Medical Sciences, Institute for Education and Training, VU University Medical Center, Amsterdam, the Netherlands Background: The field of postgraduate medical education (PGME) is continuously evolving as a result of social demands and advancing educational insights. Change experts contend that organizational readiness for change (ORC) is a critical precursor for successful implementation of change initiatives. However, in PGME, assessing change readiness is rarely considered while it could be of great value for managing educational change such as curriculum change. Therefore, in a previous Delphi study the authors developed an instrument for assessing ORC in PGME: Specialty Training’s Organizational Readiness for curriculum Change (STORC). In this study, the psychometric properties of this questionnaire were further explored.Methods: In 2015, STORC was distributed among clinical teaching teams in the Netherlands. The authors conducted a confirmatory factor analysis on the internal factor structure of STORC. The reliability of the measurements was estimated by calculating Cronbach’s alpha for all subscales. Additionally, a behavioral support-for-change measure was distributed as well to assess correlations with change-related behavior.Results: In total, the STORC questionnaire was completed by 856 clinical teaching team members from 39 specialties. Factor analysis led to the removal of 1 item but supported the expected factor structure with very good fit for the other 43 items. Supportive behavior was positively correlated to a higher level of ORC.Discussion: In this study, additional steps to collect validity evidence for the STORC questionnaire were taken successfully. The final subscales of STORC represent the core components of ORC in the literature. By breaking down this concept into multiple measurable aspects, STORC could help to enable educational leaders to diagnose possible hurdles in implementation processes and to perform specifically targeted interventions when needed. Keywords: organizational readiness for change, postgraduate medical education, curriculum change, questionnaire development, change management

Lindsay Bank,1,2 Mariëlle Jippes,3 Jimmie Leppink,4 Albert JJA Scherpbier,4 Corry den Rooyen,5 Scheltus J van Luijk,6 Fedde Scheele1,2,7 1Department of Healthcare Education, OLVG Hospital, 2Faculty of Earth and Life Sciences, Athena Institute for Transdisciplinary Research, VU University, Amsterdam, 3Department of Plastic Surgery, Erasmus Medical Centre, Rotterdam, 4Faculty of Health, Medicine and Life Sciences, School of Health Professions Education, Maastricht University, Maastricht, 5Movation BV, Maarssen, 6Department of Healthcare Education, Maastricht University Medical Center+, Maastricht, 7School of Medical Sciences, Institute for Education and Training, VU University Medical Center, Amsterdam, the Netherlands Introduction: Curriculum change and innovation are inevitable parts of progress in postgraduate medical education (PGME). Although implementing change is known to be challenging, change management principles are rarely looked at for support. Change experts contend that organizational readiness for change (ORC) is a critical precursor for the successful implementation of change initiatives. Therefore, this study explores whether assessing ORC in clinical teaching teams could help to understand how curriculum change takes place in PGME.Methods: Clinical teaching teams in hospitals in the Netherlands were requested to complete the Specialty Training’s Organizational Readiness for curriculum Change, a questionnaire to measure ORC in clinical teaching teams. In addition, change-related behavior was measured by using the “behavioral support-for-change” measure. A two-way analysis of variance was performed for all response variables of interest. Results: In total, 836 clinical teaching team members were included in this study: 288 (34.4%) trainees, 307 (36.7%) clinical staff members, and 241 (28.8%) program directors. Overall, items regarding whether the program director has the authority to lead scored higher compared with the other items. At the other end, the subscales “management support and leadership,” “project resources,” and “implementation plan” had the lowest scores in all groups.Discussion: The study brought to light that program directors are clearly in the lead when it comes to the implementation of educational innovation. Clinical teaching teams tend to work together as a team, sharing responsibilities in the implementation process. However, the results also reinforce the need for change management support in change processes in PGME. Keywords: organizational readiness for change, postgraduate medical education, curriculum change, change management, questionnaire, innovation

To this date, research on the interplay between organisational structure/managerial and organisational value/psychological elements which impact on educational quality is scarce and fragmented. As a consequence of a lack of knowledge in this area, institutions often address these elements in isolation, moving past integral approaches, which reinforce the organisations' quality culture. In order to examine interrelationships between context characteristics, work-related psychological attitudes of staff and enhancement practices, a path analysis was performed on data collected from academics with teaching coordination roles. The findings highlight the paramount importance of a 'human relation' value orientation; this orientation influences empowerment, commitment and communication satisfaction. Rational goal values and ownership are positively related to quality enhancement practices. It is advocated that institutional policies and strategies directed at educational quality enhancement should leave discretionary space for the availing of academics' expertise. Nurturing collaborative teaching/learning communities with explicit concern for morale, involvement and development, deserves further cultivation. [ABSTRACT FROM AUTHOR]

Objective. The aim of this study was to investigate how patients experience diagnostic urological procedures performed by urologists, junior residents and senior residents, and to assess the influence of procedure-related factors on patient experiences.Methods. Data were collected during 222 procedures: 84 transrectal ultrasound-guided prostate biopsies (TRUSP; urologistsn = 39, residentsn = 45) and 138 urethrocystoscopies (UCS; urologistsn = 44, residentsn = 94) in six hospitals. Patient experiences were assessed using a questionnaire focusing on pain, comfort and satisfaction (visual analogue scale, 0–10) and communication aspects on a four-point Likert scale. Clinical observations were made to identify influencing factors.Results. Median values for patient experiences across procedures were 10 (range 5–10) for patient satisfaction, 2 (0–9) for pain and 8 (0–10) for comfort. Generalized estimating equations revealed no significant differences between urologists, senior residents and junior residents in terms of experienced patient comfort, satisfaction or pain. Procedural time was longer for residents, but this did not correlate significantly with patient-experienced comfort (p = 0.3). In UCS, patient comfort and satisfaction were higher in the supine position for male and female patients, respectively (p < 0.01). In TRUSP, local anaesthesia resulted in a significant decrease in pain (p = 0.002) and an increase in comfort (p = 0.03). Finally, older patients experienced less pain and gave higher comfort and satisfaction responses than younger patients.Conclusions. Patients expressed high levels of satisfaction and comfort during diagnostic urological procedures. Experiences were not affected by the level of training, suggesting highly developed interpersonal and communication skills for residents in an early stage of residency training. Patients demonstrated significant preferences for local anaesthesia in TRUSP and performance of UCS in the supine position over the lithotomy position. [ABSTRACT FROM PUBLISHER]

Phenomenon : Social accountability has become a universal component in medical education. However, medical schools have little guidance for operationalizing and applying this concept in practice. This study explored institutional practices and administrative perceptions of social accountability in medical education. Approach : An online survey was distributed to a purposeful sample of English-speaking undergraduate medical school deans and program directors/leads from 245 institutions in 14 countries. The survey comprised of 38-items related to program mission statements, admission processes, curricular content, and educational outcomes. Survey items were developed using previous literature and categorized using a context-input-process-products (CIPP) evaluation model. Exploratory Factor Analysis (EFA) was used to assess the inter-relationship among survey items. Reliability and internal consistency of items were evaluated using McDonald's Omega. Findings : Results from 81 medical schools in 14 countries collected between February and June 2020 are presented. Institutional commonalities of social accountability were observed. However, our findings suggest programs focus predominately on educational inputs and processes, and not necessarily on outcomes. Findings from our EFA demonstrated excellent internal consistency and reliability. Four-factors were extracted: (1) selection and recruitment; (2) institutional mandates; (3) institutional activities; and (4) community awareness, accounting for 71% of the variance. McDonald's Omega reliability estimates for subscales ranged from 0.80-0.87. Insights : This study identified common practices of social accountability. While many medical schools expressed an institutional commitment to social accountability, their effects on the community remain unknown and not evaluated. Overall, this paper offers programs and educators a psychometrically supported tool to aid in the operationalization and reliability of evaluating social accountability.

Background: Developing self-regulated learning in preclinical settings is important for future lifelong learning. Previous studies indicate professional identity formation, i.e., formation of self-identity with internalized values and norms of professionalism, might promote self-regulated learning. We designed a professional identity formation-oriented reflection and learning plan format, then tested effectiveness on raising self-regulated learning in a preclinical year curriculum., Methods: A randomized controlled crossover trial was conducted using 112 students at Jichi Medical University. In six one-day problem-based learning sessions in a 7-month pre-clinical year curriculum, Groups A (n = 56, female 18, mean age 21.5y ± 0.7) and B (n = 56, female 11, mean age 21.7y ± 1.0) experienced professional identity formation-oriented format: Group A had three sessions with the intervention format in the first half, B in the second half. Between-group identity stages and self-regulated learning levels were compared using professional identity essays and the Motivated Strategies for Learning Questionnaire., Results: Two-level regression analyses showed no improvement in questionnaire categories but moderate improvement of professional identity stages over time (R 2  = 0.069), regardless of timing of intervention., Conclusions: Professional identity moderately forms during the pre-clinical year curriculum. However, neither identity nor self-regulated learning is raised significantly by limited intervention.

Purpose: Medical schools face growing pressures to produce stronger evidence of their social accountability, but measuring social accountability remains a global challenge. This narrative review aimed to identify and document common themes and indicators across large-scale social accountability frameworks to facilitate development of initial operational constructs to evaluate social accountability in medical education., Method: The authors searched 5 electronic databases and platforms and the World Wide Web to identify social accountability frameworks applicable to medical education, with a focus on medical schools. English-language, peer-reviewed documents published between 1990 and March 2019 were eligible for inclusion. Primary source social accountability frameworks that represented foundational values, principles, and parameters and were cited in subsequent papers to conceptualize social accountability were included in the analysis. Thematic synthesis was used to describe common elements across included frameworks. Descriptive themes were characterized using the context-input-process-product (CIPP) evaluation model as an organizational framework., Results: From the initial sample of 33 documents, 4 key social accountability frameworks were selected and analyzed. Six themes (with subthemes) emerged across frameworks, including shared values (core social values of relevance, quality, effectiveness, and equity; professionalism; academic freedom and clinical autonomy) and 5 indicators related to the CIPP model: context (mission statements, community partnerships, active contributions to health care policy); inputs (diversity/equity in recruitment/selection, community population health profiles); processes (curricular activities, community-based clinical training opportunities/learning exposures); products (physician resource planning, quality assurance, program evaluation and accreditation); and impacts (overall improvement in community health outcomes, reduction/prevention of health risks, morbidity/mortality of community diseases)., Conclusions: As more emphasis is placed on social accountability of medical schools, it is imperative to shift focus from educational inputs and processes to educational products and impacts. A way to begin to establish links between inputs, products, and impacts is by using the CIPP evaluation model.

Background: Previous studies indicate that a teacher-centered context could hinder undergraduates from self-regulated learning (SRL), whereas a learner-centered context could promote SRL. However, SRL development between a teacher-centered and a learner-centered context has not directly compared in undergraduate settings. Also, it is still unclear how a contextual change toward learner-centered learning could influence SRL in students, who are strongly accustomed to teacher-centered learning., Methods: We conducted three focus groups that examined 13 Japanese medical students who left a traditional curriculum composed of didactic lectures and frequent summative tests and entered a seven-month elective course (Free Course Student Doctor or FCSD). The FCSD emphasizes student-designed individualized learning with support and formative feedback from mentors chosen by students' preference. We also conducted two focus groups that examined 7 students who remained in the teacher-centered curriculum during the same period. Students were asked to discuss their 1) motivation, 2) learning strategies, and 3) self-reflection on self-study before and during the period. Data were analyzed using thematic analysis and code comparison between the two cohorts., Results: The non-FCSD participants described their motivational status as being one among a crowd set by the teacher's yardstick. Their reflection focused on minimizing the gap between themselves and the teacher-set yardstick with strategies considered monotonous and homogeneous (e.g. memorization). FCSD participants described losing the teacher-set yardstick and constructing their future self-image as an alternative yardstick. They compared gaps between their present status and future self-image by self-reflection. To fill these gaps, they actively employed learning strategies used by doctors or mentors, leading to diversification of their learning strategies., Conclusions: A contextual change toward learner-centered learning could promote SRL even in students strongly accustomed to teacher-centered learning. In the learner-centered context, students began to construct their self-image, conduct self-reflection, and seek diverse learning strategies by referring to future 'self' models.

Background: Students often perceive workplace-based learning as disconnected from what they learn in medical school. Interventions that deal with this issue regularly involve feedback and/or learning aids. Feedback has frequently been encouraged in previous research, whereas the use of aids is less understood., Objective: This study aims to investigate the added value of learning aids in making the connection and enhancing the transfer of learning between medical school and workplace-based learning., Methods: First-year students in postgraduate general practice training participated in a mixed-methods study. Within a quasi-experimental design, two conditions were investigated: (1) students having access to electronic health record (EHR)-embedded learning aids and feedback and (2) students only receiving feedback. Semistructured interviews were conducted and analyzed according to the thematic analysis approach., Results: Forty-four students participated in this study. No significant difference was found between the two conditions (t 42 =-0.511, P=.61, 95% CI -4.86 to 2.90). Nevertheless, students used the aids frequently and found them useful. Given that the aids were familiar to students and contained practice-based instructions in an easily accessible format, they were perceived as feasible to use during workplace-based learning. They also appeared to stimulate transfer of learning, self-confidence, reflection, and interaction between student and supervisor., Conclusions: Access to EHR-embedded learning aids offers additional support during, but also before and after, patient encounters. The aids can be easily implemented into workplace-based learning., (©Sanne Peters, Geraldine Clarebout, Bert Aertgeerts, Jimmie Leppink, Ann Roex. Originally published in JMIR Medical Education (http://mededu.jmir.org), 12.04.2019.)

Context: Simulated clinical immersion (SCI), in which clinical situations are simulated in a realistic environment, safely and gradually exposes novices to complex problems. Given their limited experience, undergraduate students can potentially be quite overwhelmed by SCI learning tasks, which may result in misleading learning outcomes. Although task complexity should be adapted to the learner's level of expertise, many factors, both intrinsic and extraneous to the learning task, can influence perceived task complexity and its impact on cognitive processes., Objectives: The purpose of this mixed-methods study was to understand the effects of task complexity on undergraduate pharmacy students' cognitive load, task performance and perception of learning in SCI., Methods: A total of 167 second-year pharmacy students were randomly assigned to undertake one simple and one complex learning task in SCI consecutively. Participants' cognitive load was measured after each task and debriefing. Task performance and time on task were also assessed. As part of a sequential explanatory design, semi-structured interviews were conducted with students showing maximal variations in intrinsic cognitive load to elucidate their perceptions of learning when dealing with complexity., Results: Although the complex task generated significantly higher cognitive load and time on task than the simple task, performance was high for both tasks. Qualitative results revealed that a lack of clinical experience, an unfamiliar resource in the environment and the constraints inherent to SCI, such as time limitations, hindered the clinical reasoning process and led to poorer self-evaluation of performance. Simple tasks helped students gain more self-confidence, whereas complex tasks further encouraged reflective practice during debriefings., Conclusions: Although complex tasks in SCI were more cognitively demanding and took longer to execute, students indicated that they learned more from them than they did from simple tasks. Complex tasks constitute an additional challenge in terms of clinical reasoning and thus provide a more valuable learning experience from the student's perspective., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Introduction: Medical and healthcare professionals' empathy for patients is crucially important for patient care. Some studies have suggested that a significant decline in empathy occurs during clinical training years in medical school as documented by self-assessed empathy scales. Moreover, a recent study provided qualitative evidence that communication skills training in an examination context, such as in an objective structured clinical examination, might stimulate perspective taking but inhibit the development of compassionate care. Therefore, the current study examined how perspective taking and compassionate care relate to medical students' willingness to show empathic behaviour and how these relations may change with communication skills training., Methods: A total of 295 fourth-year Japanese medical students from three universities completed the Jefferson Empathy Scale and a newly developed set of items on willingness to show empathic behaviour twice after communication skills training, pertaining to post-training and retrospectively for pre-training., Results: The findings indicate that students' willingness to show empathic behaviour is much more correlated with perspective taking than with compassionate care. Qualitative descriptive analysis of open-ended question responses revealed a difficulty of feeling compassion despite showing empathic behaviour., Discussion: These findings shed light on the conceptual structure of empathy among medical students and generate a number of hypotheses for future intervention and longitudinal studies on the relation between communication skills training and empathy.

Background and Objectives: Previous studies support the notion that East Asian medical students do not possess sufficient self-regulation for postgraduate clinical training. However, some East Asian physicians who are employed in geographically isolated and educationally underserved rural settings can self-regulate their study during the early phase of their postgraduate career. To explore the contextual attributes that contribute to self-regulated learning (SRL), we examined the differences in self-regulation between learning as an undergraduate and in a rural context in East Asia., Methods: We conducted interviews and diary data collection among rural physicians (n = 10) and undergraduates (n = 11) in Japan who undertook self-study of unfamiliar diseases. We analyzed three domains of Zimmerman's definition of SRL: learning behaviors, motivation, and metacognition using constructivist grounded theory., Results: Rural physicians recognized their identity as unique, and as professionals with a central role of handling diseases in the local community by conducting self-study. They simultaneously found themselves being at risk of providing inappropriate aid if their self-study was insufficient. They developed strategic learning strategies to cope with this high-stakes task. Undergraduates had a fear of being left behind and preferred to remain as one of the crowd with students in the same school year. Accordingly, they copied the methods of other students for self-study and used monotonous and homogeneous strategies., Conclusions: Different learning contexts do not keep East Asian learners from being self-regulated. Awareness of their unique identity leads them to view learning tasks as high-stakes, and to initiate learning strategies in a self-regulated manner. Teacher-centered education systems cause students to identify themselves as one of the crowd, and tasks as low-stakes, and to accordingly employ non-self-regulated strategies.

Introduction: Ward round skills are essential for doctors in hospital settings. Literature shows medical students' deficiencies in these skills. Simulation has been used to train these skills. However, exposing learners to simulation at an early stage may be associated with a high cognitive load and limited learning. This study aims to determine how students experience this load and its interplay with performance and which factors promote and impair learning., Methods: Fifty-six final year medical students participated in a simulated ward round training exercise. Both students' performance and cognitive load were measured to determine if there was any correlation and interviews were carried out to understand which factors support and impair learning., Results: Performance scores revealed deficiencies in ward round skills. Students experienced a cognitive load that weakly correlated with performance. Qualitative findings provided important insights into simulated ward-based learning. It is clear that well-designed clinical scenarios, prioritization tasks, teamwork and feedback support students' learning process whereas distractions impair learning., Conclusions: WRS proved to be a good teaching method to improve clinical skills at this stage as the cognitive load is not too high to impair learning. Hence, including tasks in the simulation design can enhance the learning process.

To many physicians and professionals, social media seems to be a risky business. However, recent literature has shown that there is potential to enhance your scholarly brand by engaging your stakeholders online. In this article, we discuss the opportunities presented to modern scholars by social media. Using case studies, we highlight two success stories around how scientists and scholars might use social media to enhance their careers. We also outline five key steps you can follow to build and manage your scholarly presence online., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The overall purpose of the 'Statistical Points and Pitfalls' series is to help readers and researchers alike increase awareness of how to use statistics and why/how we fall into inappropriate choices or interpretations. We hope to help readers understand common misconceptions and give clear guidance on how to avoid common pitfalls by offering simple tips to improve your reporting of quantitative research findings. Each entry discusses a commonly encountered inappropriate practice and alternatives from a pragmatic perspective with minimal mathematics involved. We encourage readers to share comments on or suggestions for this section on Twitter, using the hashtag: #mededstats.

Theory: Models on pre-assessment learning effects confirmed that task demands stand out among the factors assessors can modify in an assessment to influence learning. However, little is known about which tasks in objective structured clinical examinations (OSCEs) improve students' cognitive and metacognitive processes. Research is needed to support OSCE designs that benefit students' metacognitive strategies when they are studying, reinforcing a hypothesis-driven approach. With that intent, hypothesis-driven physical examination (HDPE) assessments ask students to elicit and interpret findings of the physical exam to reach a diagnosis ("Examine this patient with a painful shoulder to reach a diagnosis")., Hypotheses: When studying for HDPE, students will dedicate more time to hypothesis-driven discussions and practice than when studying for a part-task OSCE ("Perform the shoulder exam"). It is expected that the whole-task nature of HDPE will lead to a hypothesis-oriented use of the learning resources, a frequent use of adjustment strategies, and persistence with learning., Method: In a mixed-methods study, 40 medical students were randomly paired and filmed while studying together for two hypothetical OSCE stations. Each 25-min study period began with video cues asking to study for either a part-task OSCE or an HDPE. In a crossover design, sequences were randomized for OSCEs and contents (shoulder or spine). Time-on-task for discussions or practice were categorized as "hypothesis-driven" or "sequence of signs and maneuvers." Content analysis of focus group interviews summarized students' perception of learning resources, adjustment strategies, and persistence with learning., Results: When studying for HDPE, students allocate significantly more time for hypothesis-driven discussions and practice. Students use resources contrasting diagnoses and report persistence with learning. When studying for part-task OSCEs, time-on-task is reversed, spent on rehearsing a sequence of signs and maneuvers., Conclusions: OSCEs with similar contents but different task demands lead to opposite learning strategies regarding how students manage their study time. Measuring pre-assessment effects from a metacognitive perspective provides empirical evidence to redesign assessments for learning.

The field of medical education has adopted a wide variety of theories from other fields. A fairly recent example is cognitive load theory, which originated in educational psychology. Several empirical studies inspired by cognitive load theory and reviews of practical implications of cognitive load theory have contributed to guidelines for the design of medical education. Simultaneously, several research groups have developed instruments for the measurement of cognitive load in a medical education context. These developments notwithstanding, obtaining evidence for different types of cognitive load remains an important challenge. Therefore, the aim of this article is twofold: to provide medical educators with three key guidelines for the design of instruction and assessment and to discuss several fundamental issues in the remaining challenges presented by different types of cognitive load. The guidelines revolve around minimizing cognitive activity that does not contribute to learning, working with specific learning goals in mind, and appreciating the multifaceted relation between learning and assessment. Key issues around the types of cognitive load include the context in which learning occurs, the continued use of single-item mental effort ratings, and the timing of cognitive load and learning outcome measurements.

Children are often overconfident when monitoring their learning, which is harmful for effective control and learning. The current study investigated children's (N=167, age range 7-12years) judgments of learning (JOLs) when studying difficult concepts. The main aims were (a) to investigate how JOL accuracy is affected by accessibility cues and (b) to investigate developmental changes in implementing accessibility cues in JOLs. After studying different concepts, children were asked to generate novel sentences and then to make JOLs, select concepts for restudy, and take a final test. Overconfidence for incorrect and incomplete test responses was reduced for older children in comparison with younger children. For older age groups, generating a sentence led to greater overconfidence compared with not being able to generate a sentence, which indicates that older children relied more on accessibility cues when making JOLs. This pattern differed in the youngest age group; younger children were generally overconfident regardless of whether they had generated sentences or not. Overconfidence was disadvantageous for effective control of learning for all age groups. These findings imply that instructions to encourage children to avoid metacognitive illusions need to be adapted to children's developmental stage., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Following debates in psychology on the importance of replication research, we have also started to see pleas for a more prominent role for replication research in medical education. To enable replication research, it is of paramount importance to carefully study the reliability of the instruments we use. Cronbach's alpha has been the most widely used estimator of reliability in the field of medical education, notably as some kind of quality label of test or questionnaire scores based on multiple items or of the reliability of assessment across exam stations. However, as this narrative review outlines, Cronbach's alpha or alternative reliability statistics may complement but not replace psychometric methods such as factor analysis. Moreover, multiple-item measurements should be preferred above single-item measurements, and when using single-item measurements, coefficients as Cronbach's alpha should not be interpreted as indicators of the reliability of a single item when that item is administered after fundamentally different activities, such as learning tasks that differ in content. Finally, if we want to follow up on recent pleas for more replication research, we have to start studying the test-retest reliability of the instruments we use.

Empirical research based on groups of participants and assessment of the competence of individual students, trainees, and professionals in a given context have at least one thing in common: evidence in favour or against a hypothesis should be established by carefully considering and integrating various pieces of evidence to create a coherent story that has no contradictions, loose ends or missing elements. To provide a coherent framework for this process, this article introduces a modified version of a theory that has been used as a model of legal decision making in criminal cases: the theory of anchored narratives. In this theory, judges in a case judge the quality of pieces of evidence and whether these pieces of evidence can be anchored as narratives to form a chain of evidence that enables a decision beyond reasonable doubt regarding a suspect's guilt. This article provides examples from the domain of medicine to elaborate how a modified version of this theory can provide researchers and educators with a framework in which the assessment of both empirical research and competence is a qualitative professional judgement based on an integration of various sources of qualitative and quantitative information.

Context: Simulated clinical immersion (SCI) is used in undergraduate healthcare programs to expose the learner to real-life situations in authentic simulated clinical environments. For novices, the environment in which the simulation occurs can be distracting and stressful, hence potentially compromising learning., Objectives: This study aims to determine whether SCI (with environment) imposes greater extraneous cognitive load and stress on undergraduate pharmacy students than simulated patients (SP) (without environment). It also aims to explore how features of the simulated environment influence students' perception of learning., Methods: In this mixed-methods study, 143 undergraduate pharmacy students experienced both SCI and SP in a crossover design. After the simulations, participants rated their cognitive load and emotions. Thirty-five students met in focus groups to explore their perception of learning in simulation., Results: Intrinsic and extraneous cognitive load and stress scores in SCI were significantly but modestly higher compared to SP. Qualitative findings reveal that the physical environment in SCI generated more stress and affected students? focus. In SP, students concentrated on clinical reasoning. SCI stimulated a focus on data collection but impeded in-depth problem solving processes., Conclusion: The physical environment in simulation influences what and how students learn. SCI was reported as more cognitively demanding than SP. Our findings emphasize the need for the development of adapted instructional design guidelines in simulation for novices.

The goal of science is to establish laws and principles that can help us explain phenomena in our world and universe in a systematic manner and, in many cases, how we may be able to predict and/or influence these phenomena. In this endeavour, qualitative and quantitative research methods can provide us with useful tools. However, these methods have been assigned several unconstructive labels that, although perceived as useful anchors, can result in ill-founded choices of methods used in a study. This article discusses several of these frequently encountered labels and argues that they may contribute to a continued quantitative-qualitative divide, as we have witnessed in the field of medical education, but are not constructive for the practice of science. To establish laws and principles, we need well-designed scientific studies and replications of these studies. Regardless of which methods we use, to enable replication, we need to document all choices and decisions made throughout a study.