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Adaptive expertise (AE) and reflective practice (RP), two influential and resonant theories of professional expertise and practice in their own right, may further benefit health professions education if carefully combined. The current societal and systemic context is primed for both AE and RP. Both bodies of work position practitioners as agentive, learning continually and thoughtfully throughout their careers, particularly in order to manage unprecedented situations well. Similar on the surface, the roots and practices of AE and RP diverge at key junctures and we will focus on RP's movement toward "critically" reflective practice. The roots of AE and RP, and how they relate to or diverge from present-day applications matter because in health professions education, as in all education, paradigmatic mixing should be undertaken purposefully. This paper will explore the need for AE and RP, their shared commitments, distinctive histories, pedagogical possibilities both individually and combined, and next steps for maximizing their potential to positively impact the field. We argue that this exploration is urgently needed because both AE and RP hold much promise for improving health care and yet employing them optimally--whether alone or together--requires understanding and intent. We build an interprofessional education case situated in long-term care, throughout the paper, to demonstrate the potential that AE and RP might offer to health professions education individually and combined. This exploration comes just in time. Within the realities of uncertain practice emphasized by the pandemic, practitioners were also called to act in response to complex and urgent social movements. A combined AE and RP approach, with focus on critically reflective practice in particular, would potentially prepare professionals to respond effectively, compassionately, and equitably to future health and social crises and challenges.

Residents must develop knowledge, skills, and attitudes to handle a rapidly developing clinical environment. To address this need, adaptive expertise has been suggested as an important framework for health professions education. However, research has yet to explore the relationship between workplace learning and adaptive expertise. This study sought to investigate how clinical supervision might support the development of adaptive expertise. The present study used a focused ethnography in two emergency departments. We observed 75 supervising situations with the 27 residents resulting in 116 pages of field notes. The majority of supervision was provided by senior physicians, but also included other healthcare professionals. We found that supervision could serve two purposes: closure and discovery. Supervision aimed at discovery included practices that reflected instructional approaches said to promote adaptive expertise, such as productive struggle. Supervision aimed at closure-included practices with instructional approaches deemed important for efficient and safe patient care, such as verifying information. Our results suggest that supervision is a shared practice and responsibility. We argue that setting and aligning expectations before engaging in supervision is important. Furthermore, results demonstrated that supervision was a dynamic process, shifting between both orientations, and that supervision aimed at discovery could be an an appropriate mode of supervision, even in the most demanding clinical situations.

"Advances in Health Sciences Education" ("AHSE") has been at the forefront of the cognitive wave in health professions education for the past 25 years. One example is research on productive failure, a teaching strategy that asks learners to attempt to generate solutions to difficult problems before receiving instruction. This study compared the effectiveness of productive failure with indirect failure to further characterize the underpinning cognitive mechanisms of productive failure. Year one pharmacy students (N = 42) were randomly assigned to a productive failure or an indirect failure learning condition. The problem of estimating renal function based on serum creatinine was described to participants in the productive failure learning condition, who were then asked to generate a solution. Participants in the indirect failure condition learned about the same problem and were given incorrect solutions that other students had created, as well as the Cockcroft-Gault formula, and asked to compare and contrast the equations. Immediately thereafter all participants completed a series of tests designed to assess acquisition, application, and preparation for future learning (PFL). The tests were repeated after a 1-week delay. Participants in the productive failure condition outperformed those in the indirect failure condition, both on the immediate PFL assessment, and after a 1-week delay. These results emphasize the crucial role of generation in learning. When preparing novice students to learn new knowledge in the future, generating solutions to problems prior to instruction may be more effective than simply learning about someone else's mistakes. Struggle and failure are most productive when experienced personally by a learner because it requires the learner to engage in generation, which deepens conceptual understanding.

The objective of scientific, or more broadly, academic knowledge is to provide an understanding of the social and natural world that lies beyond common sense and everyday thinking. Academics use an array of techniques, methods and conceptual apparatuses to achieve this goal. The question we explore in this essay is the following: Does the grounded theory approach, in the constructivist version developed by Kathy Charmaz, provide the necessary methodological tools for the creation of knowledge and theories beyond everyday thinking? To conduct our analysis, we have drawn on the rationalist epistemology originally developed by Gaston Bachelard and taken up a few decades later by Pierre Bourdieu and colleagues to look at the epistemological foundation of the CGT methods as defined by Charmaz. We focussed on two distinctive epistemological features characterising constructivist grounded theory (CGT): the use of inductive reasoning to generate interpretative theory; and the primacy of subjectivity over objectivity as the preferred path to knowledge making. While the usefulness of CGT for conducting qualitative research and understanding the perspective of social actors has been acknowledged by scholars in health professions education research and other research areas, the inductivist logic on which it draws raises questions concerning the nature of the knowledge yielded by this approach. As we argue in this article, it is still unclear in what way the interpretative theory generated by CGT is not a duplication of everyday thinking expressed through meta-narratives. It is also unclear how the understanding of social phenomena can be refined if the use of inductive procedures logically implies the creation of a new theory each time a study is conducted. We engage with these questions to broaden the epistemological conversation within the health professions education research community. It is our hope that scholars in the field will engage in this epistemological conversation and advance it in new directions.

Productive failure is an instructional approach that requires learners to struggle as they attempt to generate solutions to problems before, rather than after, receiving direct instruction on a targeted concept. Studies demonstrate that productive failure prepares students for later learning of new, related knowledge. Our study explored the effectiveness of productive failure as an instructional intervention in health professions education with respect to (a) acquisition and application of a novel concept, and (b) learners' preparation for future learning of new, related content. Forty year-one students enrolled in the Doctor of Pharmacy program at the University of Toronto were randomly assigned to a productive failure (i.e. attempt to generate solutions before receiving instruction) or direct instruction only learning condition. After a practice phase, participants completed a series of tests designed to measure knowledge acquisition, knowledge application, and preparation for future learning (new learning is required for successful problem solving). As expected, no difference in performance was seen between participants on the acquisition and application tests. However, participants in the productive failure condition outperformed those in the direct instruction condition on the preparation for future learning test. These results emphasize the role of struggle in learning and support the theory that engaging students in solving problems that are beyond their abilities can be a productive exercise in failure. The results suggest that productive failure assists learners in acquiring the conceptual knowledge needed to facilitate learning in the future.

Purpose: The incoming Canadian cohort of medical students is comprised mainly of individuals from Generation Z (Gen Z; born between 1997 and 2012), with greater than 50% of applicants identifying as female. A gap remains in our understanding of Gen Z women learners in their challenges in navigating medical education, their expectations for their medical careers and the influences that have impacted their worldview. This study explored the needs, values, and experiences of Gen Z women medical students and the impact of these factors on mentorship expectations among this population that will soon be entering the workforce. Methods: Upon receiving ethics approval from the University of Toronto Research Ethics Board, semi‐structured interviews were conducted (February–May 2021) with 15 Gen Z women students from 14 English‐speaking Canadian medical schools who had given written consent to participate. An iterative constant comparative team approach was utilised in which the interview guide and sampling were adjusted as the data evolved. Transcripts were line by line coded into categories, then grouped into themes using descriptive analysis. Results: These socially aware learners described how society had afforded them greater opportunities for expression, which gave them a sense of feeling advantaged over older generations. However, participants paradoxically expressed feelings of powerlessness and commented on tensions they experienced when interacting with older generation physician mentors, especially during conversations on social justice issues. They also highlighted instances of biased mentorship specific to their gender. Participants emphasised a desire for inclusive mentorship that considered the mentee's identity and intersectionality. Conclusions: The growing number of women learners in Canadian medical schools necessitates a re‐evaluation of mentorship delivery. Mentors must adapt by integrating Gen Z ideals to overcome mentorship challenges. [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]

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Background: Given current health system trends, clinicians increasingly care for patients with complex care needs. There is a recognized lack of evidence to support clinician decision-making in these situations, as complex or multimorbid patients have been historically excluded from the types of research that inform clinical practice guidelines. However, expert clinicians at sites of excellence (e.g., Stroke Distinction sites) provide measurably excellent care. We sought to review profession-specific competency frameworks to locate information that may be supporting the development of clinician expertise when managing the care of patients with complex care needs. Methods: We conducted a review of the professional competency frameworks for core members of the inpatient stroke rehabilitation team, to determine the degree of guidance and/or preparation for the management of patients with complex care needs. We developed and applied an assessment rubric to locate references to patient complexity, multimorbidity and complexity theory. Results: Across the professional competency frameworks, there are some references to complexity at patient- and team-levels; there are fewer references to system-level complexity. We noted a lack of clear guidance for clinicians regarding the management of patients with complex care needs. Conclusion: Further research is needed to explore how clinicians develop expertise in the management of patients with complex care needs, as we noted minimal guidance in the professional competency frameworks. However, we suggest that integrating complexity-related language into professional competency frameworks could better prime novice clinicians for new learning in the workplace and ease their transition into working in a complex context. [ABSTRACT FROM AUTHOR]

Clinicians' purposeful improvement of practice is vital to maintaining excellence in patient care. This activity is understood as a core competency of adaptive expertise. As part of a broader program of research exploring adaptive expertise in healthcare, this study explored purposeful improvement in paediatric minimally invasive surgery. A cognitive ethnography was conducted, with the aim of identifying and elaborating distributed cognitive processes that occur when an individual enacts purposeful improvements in a clinical context. A saturation sample of data from weekly pre-operative meetings, 13 observed minimally invasive procedures and 12 semi-structured interviews was collected over 6 months. A concurrent analysis of field notes and transcribed interviews was done inductively to uncover emergent themes. An audit trail was maintained throughout the research. We analyzed the interview and observation data with particular attention to the ways in which the activity of purposeful improvement is distributed socially (e.g. patient families, health care team) and materially (e.g. procedure, patient position, instruments, OR equipment) as well as over time (i.e. before, during and after). These results made visible the distributed nature of purposeful improvement, building on our understanding of this important adaptive expert activity in clinical settings and suggesting implications for more effective training of future adaptive experts. In particular, our results inform how purposeful improvement can occur during daily work and highlight two related forms of integration that occur during this activity: integration of individual competencies and integration of individuals and their social and material context.

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]

The ability to guide one's own learning is an essential skill for the health professional. The apprenticeship model of undergraduate education offers an opportunity to engage in self-regulated learning as students work to set goals, evaluate the available opportunities and seek out those with the greatest potential for learning. A close examination of how students navigate their clinical rotations could therefore foster greater understanding of how students learn to guide their own learning. The study presented here aimed to examine undergraduate medical students' day-to-day learning strategies in order to better understand the process of informal self-regulated learning in practice. As a secondary objective, we sought to provide a forum for students to share and critically reflect on their own self-regulated learning strategies. A series of focus groups were conducted with medical students on a surgical rotation. Participants were asked to discuss issues relating to the strategies and behaviours that they had implemented in order to maximize their educational experience. Three distinct approaches to informal self-regulated learning were identified: Participants articulated tendencies to acquiesce to a perceived lack of learning opportunities choose from available learning opportunities and create their own learning opportunities. The results are interpreted through the lens of self-regulated learning theory and implications for medical education are discussed. (Contains 1 table.)