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Background: Surgeons should transform their residents to take the lead in their jobs and optimize their working conditions, so-called job crafting. We investigated the actions undertaken by surgeons with a transformational leadership style to encourage residents' job crafting, about which there is at present a paucity of information. Methods: We performed a qualitative study based on principles of constructivist grounded theory. In-depth interviews were held with a purposive sample of surgeons who were perceived as transformational leaders by their residents. During data analysis (open, axial, and selective coding), we compared inductive codes with deductive codes drawn from the job demands-resources and transformational leadership theories to reach a consensus on the interpretation of data and identification of the main themes. Results: Sixteen surgeons participated. Surgeons undertook five actions that enhanced job crafting in residents. They: one) modeled positive behaviors of a good surgeon; two) used a stepwise individual approach toward autonomy; three) connected with the resident as a person; four) supported residents in handling complications and errors; and five) they coached the resident to deal with competing interests. These actions had four consequences for residents. They led to: one) more responsibilities in patient care; two) more constructive relationships in the workplace; three) less pressure from workload and surgical care duties; and four) less personal difficulties and errors in patient care. Conclusions: The actions undertaken by surgeons with a transformational leadership style have a positive association with the residents' ability to craft their jobs. This knowledge has implications for surgeons' leadership development with a view to workplace education. (c) 2021 Elsevier Inc. All rights reserved.

Off-the-job faculty development for clinical teachers has been blighted by poor attendance, unsatisfactory sustainability, and weak impact. The faculty development literature has attributed these problems to the marginalisation of the clinical teacher role in host institutions. By focusing on macro-organisational factors, faculty development is ignoring the how clinical teachers are shaped by their everyday participation in micro-organisations such as clinical teams. We set out to explore how the roles of clinical teacher and graduate learner are co-constructed in the context of everyday work in clinical teams. Using an ethnographic study design we carried out marginal participant observation of four different hospital clinical teams. We assembled a dataset comprising field notes, participant interviews, images, and video, which captured day-to-day working and learning encounters between team members. We applied the dramaturgical sensitising concepts of impression management and face work to a thematic analysis of the dataset. We found that learning in clinical teams was largely informal. Clinical teachers modelled, but rarely articulated, an implicit curriculum of norms, standards and expectations. Trainees sought to establish legitimacy and credibility for themselves by creating impressions of being able to recognise and reproduce lead clinicians’ standards. Teachers and trainees colluded in using face work strategies to sustain favourable impressions but, in so doing, diminished learning opportunities and undermined educational dialogue. These finding suggest that there is a complex interrelationship between membership of clinical teams and clinical learning. The implication for faculty development is that it needs to move beyond its current emphasis on the structuring effects of institutional context to a deeper consideration of how teacher and learner roles are co-constructed in clinical teams.

Purpose Most clinical teachers have not been trained to teach, and faculty development for clinical teachers is undermined by poor attendance, inadequate knowledge transfer, and unsustainability. A crucial question for faculty developers to consider is how clinicians become teachers "on the job." Such knowledge is important in the design of future workplace-based faculty development initiatives. The authors conducted a scoping review of research on the relationship between becoming a clinical teacher and the clinical environments in which those teachers work. Method In June 2017, using the scoping review design described by Levac et al (2010), the authors searched 12 databases. They subjected the articles discovered to four phases of screening, using iteratively developed inclusion/exclusion criteria. They charted data from the final selection of articles and used thematic analysis to synthesize findings. Results Thirty-four research reports met the inclusion criteria. Most (n = 24) took an individualist stance toward identity, focusing on how teachers individually construct their teacher identity in tension with their clinician identities. Only 10 studies conceptualized clinical teacher identity formation as a social relational phenomenon, negotiated within hierarchical social structures. Twenty-nine of the included studies made little or no use of explicit theoretical frameworks, which limited their rigor and transferability. Conclusions Clinicians reconciled their identities as teachers with their identities as clinicians by juggling the two, finding mutuality between them, or forging merged identities that minimized tensions between educational and clinical roles. They did so in hierarchical social settings where patient care and research were prioritized above teaching.

Phenomenon: Interdisciplinary coteaching has become a popular pedagogic model in medical education, yet there is insufficient research to guide effective practices in this context. Coteaching relationships are not always effective, which has the potential to affect the student experience. The purpose of this study was to explore interdisciplinary coteaching relationships between a physician (MD) and social behavioral scientist (SBS) in an undergraduate clinical skills course. We aimed to gain an in-depth understanding of what teachers perceive as influencing the quality of relationships to begin to construct a framework for collaborative teaching in medical education. Approach: A qualitative study was conducted consisting of 12 semistructured interviews (6 MD and 6 SBS) and 2 monodisciplinary focus groups. Sampling was purposive and aimed at maximal variation from among 64 possible faculty. The data were analyzed using the constant comparative method to develop a grounded theory. Findings: Five major themes resulted from the analysis that outline a framework for interdisciplinary coteaching: respect, shared goals, shared knowledge and understanding, communication, and complementary pairings. Insights: The first 4 themes align with elements of relational coordination theory, an organizational theory of collaborative practice that describes how work roles interact. The complementary pairings extend this theory from work roles to individuals, with unique identities and personal beliefs and values about teaching. Prior studies on coteaching have not provided a clear linkage to theory. The conceptual framework helps suggest future directions for coteaching research and has practical implications for administrative practices and faculty development. These findings contribute to the sparse research in medical education on interdisciplinary coteaching relationships.

Background: In medical education, students need to acquire skills to self-direct(ed) learning (SDL), to enable their development into self-directing and reflective professionals. This study addressed the mentor perspective on how processes in the mentor-student interaction influenced development of SDL.Methods:n=22 mentors of a graduate-entry medical school with a problem-based curriculum and longitudinal mentoring system were interviewed (n=1 recording failed). Using activity theory (AT) as a theoretical framework, thematic analysis was applied to the interview data to identify important themes.Results: Four themes emerged: centered around the role of the portfolio, guiding of students' SDL in the context of assessment procedures, mentor-role boundaries and longitudinal development of skills by both the mentor and mentee. Application of AT showed that in the interactions between themes tensions or supportive factors could emerge for activities in the mentoring process.Conclusion: The mentors' perspective on coaching and development of reflection and SDL of medical students yielded important insights into factors that can hinder or support students' SDL, during a longitudinal mentor-student interaction. Coaching skills of the mentor, the interaction with a portfolio and the context of a mentor community are important factors in a longitudinal mentor-student interaction that can translate to students' SDL skills.

Background: In health profession education, learners are often coached by mentors for development of competencies, self-direction of learning and professionalism. It is important that the mentee-mentor relationship is aligned in terms of mutual expectations.Methods: A dual-purpose questionnaire capturing both the mentor and mentee perceptions on the actual and preferred mentoring functions was designed and validated, by performing a principal component analysis (PCA) using the data of mentees (n = 103) and mentors (n = 23) of a medical course. As a proof of concept, alignment of needs and changes in the mentoring perceptions in mentee groups of different years were determined.Results: PCA showed that specific sets of questions addressed important elements in the mentoring process, such as self-direction of learning and reflection (Scale 1), guidance of behavioural change (Scale 4), addressing personal issues and professional identity development (Scale 3 and 5) and how the mentor and mentee presents oneself in the mentoring relationship (Scale 2). Mentors and mentees perceived comparable situations as critical for an effective mentoring process, such as mentor presence and guidance of reflection, although there was also evidence of gaps, such as perception of cultural issues. By comparison of the mentee groups in the different years of the program, the dynamic or evolving nature of the mentor process became evident, mentees experienced more emphasis by the mentor on reflection (Scale 1), at a constant level of mentor presence (Scale 2).Conclusion: Given the individualized, context-specific, and dynamic nature of mentoring, programmes would benefit from a regular evaluation of mentoring practices, e.g. by using questionnaires, in order to facilitate organizational revisions and further development of the mentoring competencies.

This article was migrated. The article was marked as recommended. Introduction: Interdisciplinary co-teaching by physicians (MD) and social behavioural scientists (SBS) has emerged as an innovative teaching practice in clinical skills courses, but little is known about how co-teachers operationalize instruction. The purpose of this study was to explore the shared mental model of co-teachers concerning medical interviewing and physical examination instruction. Methods: Twelve individual semi-structured interviews were conducted at Brown University. Participants were asked, "What and how do MD and SBS faculty contribute to teaching medical interviewing and physical examination skills?" Transcripts were subjected to thematic analysis. Discourse analysis was also used to determine if what faculty individually described as contributing to instruction was observed by the co-teacher. Results: Physician and SBS faculty emphasized different but complementary aspects of medical interviewing and physical examination skills. Physicians focused on content, targeting clinical reasoning, differential diagnosis, economy of movement, efficiency, synthesis, and technical skills. SBS faculty focused on process,emphasizing active listening, presence, non-verbal communication, rapport building, empathy, and patient comfort. Discussion: Co-teachers consistently articulated their relative contributions to teaching medical interviewing and physical examinations. Their shared mental model emphasized the importance of both content and process, creating a learning environment supporting the development of both biomedical and patient-centred perspectives.

Student evaluation committees play a crucial role in internal quality assurance processes as representatives of the student body. However, the students on these committees sometimes experience difficulty in providing constructive and structured feedback to faculty in an environment characterised by a strong power differential between student and staff. This study aimed to evaluate a leadership and quality assurance training implemented for students involved in internal quality assurance. Furthermore, we explored how students give shape to their internal quality assurance role. Students from three health sciences programmes participated in a mixed methods study to evaluate the training and reflect on their internal quality assurance role. Overall, the students were very enthusiastic about the training. Qualitative data analysis indicated that in their internal quality assurance role, students: (1) harnessed the power of the entire student population; (2) tried to create focus and take charge; (3) searched for a common ground with staff, and (4) they explained how they dealt with the power differential. Providing training for students with internal quality assurance roles is a valuable endeavour. Future research needs to investigate further ways to help students to contribute to internal quality assurance processes in higher education.

Background: Attrition in surgical training, a result of poor well-being at work, continues to rise. Work engagement and persistence, the other side of the coin, depend on the proactivity of residents to optimize the demands and resources in the workplace to achieve a better fit with the environment. This type of proactivity refers to job-crafting. In this study, we sought to explore the specific mechanisms underlying residents' job-crafting to enhance work engagement and persistence, as well as the role of supervisors in this endeavor.Materials and methods: We used a constructivist-grounded theory design. We conducted semistructured interviews of active residents. During the analysis of verbatim protocols, we developed codes and categories and identified the main themes (job-crafting mechanisms) related to work engagement and persistence. We anticipated procedures to engage in reflexivity.Results: The residents showed six job-crafting mechanisms (build trust with supervisors, manage proactively, seek help, see errors and frustrations as learning opportunities, find a suitable work-life balance, and seek challenges actively). The supervisors contributed to residents' job-crafting with four mechanisms (earning the trust of the residents, providing guidance and support, allowing residents to fulfill tasks befitting a surgeon in training, and offering increasingly challenging tasks to residents).Conclusions: Work engagement and persistence in training are active processes that depend on the ability of residents to take advantage of resources and challenges and to diminish hindering demands at the workplace. Future research should focus on the perspectives of the supervisor, as well as on the effectiveness of job-crafting interventions, to enhance work engagement. (C) 2019 Elsevier Inc. All rights reserved.

Background: Teaching and learning with patient video cases may add authenticity, enhance diagnostic accuracy and improve chances of early diagnosis. The aim of this study is firstly to identify selection criteria for key Patient video cases (PVCs), secondly to identify trends in relevance of PVCs for learner levels and thirdly, to rank PVCs for learner levels. Methods: Based on a literature review, we identified criteria for key PVCs for use in paediatric neurology. We then performed a multi-round Delphi analysis to obtain agreement between 28 expert clinician teachers concerning key PVCs for four learner levels. Results: We identified two major criteria: key PVCs should demonstrate key movements, and these movements should be subtle and/or difficult to note. The expert clinician teachers subsequently assessed a list of 14 topics for key PVCs. We found a clear, increasing trend in relevance scores, from medical students to young residents to experienced residents and specialists. For medical students and residents, epileptic spasms, Down syndrome, developmental delay, cerebral palsy and absence epilepsy were highly ranked. For specialists, conditions like chorea, focal seizures or eye movement disorders topped the ranking list, although ranking was less clear for this group of advanced learners. Discussion and conclusion: Key PVCs should demonstrate movements that are difficult to note for learners. Ranked lists of key PVCs for teaching and learning at different learner levels are now available and may help institutions build validated local libraries of PVCs. (C) 2017 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.

Objective The intention to leave surgical training, hereinafter referred as proxy of “attrition,” is associated with poor well-being in the workplace. Attrition is suggested to diminish when residents possess job-crafting skills, that is, the ability to redefine their job in meaningful ways and maximize well-being at work by increasing structural and social resources and challenges and decreasing hindering demands. However, the evidence supporting this relationship is scant. This study sought to: 1) investigate to what extent residents possess job-crafting skills and compare residents’ levels of job-crafting skills across years of residency training; 2) investigate the relationship between job crafting, well-being as measured by burnout and work-engagement rates, and the intention to leave; and 3) compare the levels of job-crafting skills and well-being between residents with and without serious intentions to leave. Methods This cross sectional study was conducted in fifteen residency programs in Colombia. Surgical residents completed different questionnaires including the Dutch Job Crafting Scale (DJCS), MBI-Human Services Survey (MBI-HSS), Utrecht Work Engagement Scale (UWES-17) and an adapted version of the Nurse Turnover Intention Scale (NTIS). The objectives were addressed by independent analyses of variance (ANOVA), structural equation modeling techniques (SEM) and independent t-tests, respectively. Results A total of 202 residents participated. Residents generally scored high on their job-crafting skills to increase structural and social resources as well as challenging demands, but were less positive about their skills to reduce hindering demands. No differences across years of training were found. Job crafting correlated positively with work-engagement, which was inversely related to the intention to leave. Conversely, job crafting correlated negatively with burnout, which bore a positive relationship to the intention to leave. Residents with serious intentions to leave exhibited lower levels of most job-crafting skills and work-engagement, compared to those without such intentions. Conclusions This study adds evidence that attrition is a process mediated by residents’ well being at work, which can be molded by their job-crafting endeavors. Future research is needed to evaluate the effectiveness of interventions aimed at cultivating resident’s job-crafting abilities in order to reduce attrition.

ObjectiveThe intention to leave surgical training, hereinafter referred as proxy of "attrition," is associated with poor well-being in the workplace. Attrition is suggested to diminish when residents possess job-crafting skills, that is, the ability to redefine their job in meaningful ways and maximize well-being at work by increasing structural and social resources and challenges and decreasing hindering demands. However, the evidence supporting this relationship is scant. This study sought to: 1) investigate to what extent residents possess job-crafting skills and compare residents' levels of job-crafting skills across years of residency training; 2) investigate the relationship between job crafting, well-being as measured by burnout and work-engagement rates, and the intention to leave; and 3) compare the levels of job-crafting skills and well-being between residents with and without serious intentions to leave.MethodsThis cross sectional study was conducted in fifteen residency programs in Colombia. Surgical residents completed different questionnaires including the Dutch Job Crafting Scale (DJCS), MBI-Human Services Survey (MBI-HSS), Utrecht Work Engagement Scale (UWES-17) and an adapted version of the Nurse Turnover Intention Scale (NTIS). The objectives were addressed by independent analyses of variance (ANOVA), structural equation modeling techniques (SEM) and independent t-tests, respectively.ResultsA total of 202 residents participated. Residents generally scored high on their job-crafting skills to increase structural and social resources as well as challenging demands, but were less positive about their skills to reduce hindering demands. No differences across years of training were found. Job crafting correlated positively with work-engagement, which was inversely related to the intention to leave. Conversely, job crafting correlated negatively with burnout, which bore a positive relationship to the intention to leave. Residents with serious intentions to leave exhibited lower levels of most job-crafting skills and work-engagement, compared to those without such intentions.ConclusionsThis study adds evidence that attrition is a process mediated by residents' well being at work, which can be molded by their job-crafting endeavors. Future research is needed to evaluate the effectiveness of interventions aimed at cultivating resident's job-crafting abilities in order to reduce attrition.

Context: Only a small proportion of knowledge and skills acquired during faculty development is actually applied on the job, leading to poor transfer of training. This results in wastage of training efforts. The present study was designed to predict the intention to transfer after participation in a faculty development workshop using theory of planned behavior (TPB). Methods: A questionnaire was designed covering direct measures of the TPB constructs viz. ‘attitudes towards behavior’, ‘perceived control over behavior’ and ‘subjective norms’, which was used to predict intention to transfer. Three hundred twenty four mid-level medical educators took the survey. Results: Respondents had a mean of 10.59 ± 7.39 and 5.25 ± 5.24 years of experience of teaching undergraduate and postgraduate classes respectively. The model accounted for 41% change in intention to transfer, with standard regression co-efficient equal to 0.51 for ‘attitudes towards behavior’, 0.21 for ‘perceived control over behavior’ and 0.07 for ‘subjective norm’. Discussion: Attitudes towards behavior and perceived control over behavior had greater influence over intention to transfer compared to subjective norms. The faculty development programs should focus on developing positive attitudes and perceived control over behavior of the participants.

Learning from error is not just an individual endeavour. Organisations also learn from error. Hospitals provide many learning opportunities, which can be formal or informal. Informal learning from error in hospitals has not been researched in much depth so this narrative review focuses on five learning opportunities: morbidity and mortality conferences, incident reporting systems, patient claims and complaints, chart review and prospective risk analysis. For each of them we describe: (1) what can be learnt, categorised according to the seven CanMEDS competencies; (2) how it is possible to learn from them, analysed against a model of informal and incidental learning; and (3) how this learning can be enhanced. All CanMEDS competencies could be enhanced, but there was a particular focus on the roles of medical expert and manager. Informal learning occurred mostly through reflection and action and was often linked to the learning of others. Most important to enhance informal learning from these learning opportunities was the realisation of a climate of collaboration and trust. Possible new directions for future research on informal learning from error in hospitals might focus on ways to measure informal learning and the balance between formal and informal learning. Finally, 12 recommendations about how hospitals could enhance informal learning within their organisation are given.

Most teacher development initiatives focus on enhancing knowledge of teaching (pedagogy), whilst largely ignoring other important features of teacher knowledge such as subject matter knowledge and awareness of the learning context. Furthermore, teachers' ability to learn from faculty development interventions is limited by their existing (often implicit) pedagogical knowledge and beliefs. Pedagogical content knowledge (PCK) represents a model of teacher knowledge incorporating what they know about subject matter, pedagogy and context. PCK can be used to explore teachers' prior knowledge and to structure faculty development programmes so that they take account of a broader range of teachers' knowledge. We set out to examine the application of a PCK model in a general practice education setting.This study is part of a larger study that employed a mixed method approach (concept mapping, phenomenological interviews and video-stimulated recall) to explore features of GP teachers' subject matter knowledge, pedagogical knowledge and knowledge of the learning environment in the context of a general practice tutorial.This paper presents data on GP teachers' pedagogical and context knowledge. There was considerable overlap between different GP teachers' knowledge and beliefs about learners and the clinical learning environment (i.e. knowledge of context). The teachers' beliefs about learners were largely based on assumptions derived from their own student experiences. There were stark differences, however, between teachers in terms of pedagogical knowledge, particularly in terms of their teaching orientations (i.e. transmission or facilitation orientation) and this was manifest in their teaching behaviours.PCK represents a useful model for conceptualising clinical teacher prior knowledge in three domains, namely subject matter, learning context and pedagogy. It can and should be used as a simple guiding framework by faculty developers to inform the design and delivery of their faculty development programmes.

ACADEMIC EMERGENCY MEDICINE 2012; 19:189–194 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Program evaluation remains a critical but underutilized step in medical education. This study compared traditional and retrospective pre–post self-assessment methods to objective learning measures to assess which correlated better to actual learning. Methods: Forty-seven medical students participated in a 4-hour pediatric resuscitation course. They completed pre and post self-assessments on pediatric resuscitation and two distracter topics. Postcourse, students also retrospectively rated their understanding as it was precourse (the “retrospective pre” instrument). Changes in traditional and retrospective pre- to postcourse self-assessment measures were compared to an objectives-based multiple-choice exam. Results: The traditional pre to post self-assessment means showed an increase from 1.9 of 5 to 3.7 of 5 (p

Introduction The emphasis on the importance of professionalism in a recent CoBaTrICE-IT paper was impressive. However, insight into the elements of professionalism as perceived relevant for intensivists from the fellows’ view, and how these are taught and learned, is limited. Objectives and methods A nationwide study was performed in 2007–2008. All ICM fellows (n = 90) were sent a questionnaire containing the following questions regarding training in professionalism (7-point Likert scale (1 = very inadequate, 7 = very adequate)): which are the elements perceived to be important in intensivists’’ daily practice (38 items, cat. I)? Which methods of learning and teaching are recognised (16 items, cat. II)? Which methods of teaching and learning are considered especially useful (16 items, cat. III)? Finally, the perceived quantity and quality of formal and informal learning methods, as well as the responsible organisational body was studied. Data were analysed using SPSS 15.0. Results Response was 75.5 % (n = 68), mean age 34 years. Regarding Elements, scores on virtually all items were high. The factor ‘striving for excellence’ explained half the variance. Two other aspects, ‘Teamwork’ and ‘Dealing with ethical dilemmas’, were identified. Regarding Methods, three dimensions, ‘formal curriculum’’, ‘private and academic experiences’ and ‘role modelling’, proved important. The factor ‘formal curriculum’ explained most of the variance. Regarding Usefulness the same factors, now mainly explained by the factor Private and academic experiences, emerged with variance. In both categories the items ‘observations in daily practice’ and ‘watching television programmes like ER and House’ were the highest- and lowest-scoring items (5.99 and 5.81, and 2.69 and 2.49, respectively). Mean scores regarding the quantity of formal and informal teaching were 4.06 and 4.58 (range 1.841 and 1.519). For the quality of teaching, the figures were 4.22 and 4.52 (range 1.659 and 1.560, respectively). 54 suggestions for improvement of teaching were documented. The need for some form of formal teaching of professionalism aspects as well as for feedback was most frequently mentioned (n = 19 and 16). The local training centres are considered and should remain pivotal for teaching professionalism issues (n = 17 and 28). Conclusions Almost all elements of professionalism were considered relevant to intensivists’ daily practice. Although formal teaching methods regarding professionalism aspects are easily recognised in daily practice, learning by personal experiences and informal ways quantitatively plays a more important, and more valued role. Qualitative comments, nevertheless, stress the need for providing and receiving (solicited and unsolicited) feedback, thereby requesting expansion of formal teaching methods. The local training centres (should continue to) play a major role in teaching professionalism, although an additional role for the (inter)national intensive care organisations remains.

Given the changes in society we are experiencing, the increasing focus on patient centred care and acknowledgment that medical education needs to continue not only in the residency programmes but throughout the doctors career, is not surprising. This article describes the attention currently paid to professionalism in the residency programmes, differences in perception of professionalism between patients, faculty, students and residents, differences in professionalism issues in the different educational phases, as well as their consequences for training and assessment regarding professionalism. Continuous medical education in professionalism is thereafter briefly discussed.

Small-group learning is advocated for enhancing higher-order thinking and the development of skills and attitudes. Teacher performance, group interaction and the quality of assignments have been shown to affect small-group learning in hybrid and problem-based curricula.This study aimed to examine the perceptions of student groups as to how teacher performance, group interaction and the quality of assignments are related to one another and to learning effects in seminars of 15-30 students in a hybrid curriculum.We constructed a 28-item questionnaire and administered it to 639 students attending 32 seminars in Years 1-4 of an undergraduate veterinary curriculum. We performed factor analysis and reliability analysis of the questionnaire. We used correlation and regression analyses to explore the interactions of the four-factor model, with teacher performance, group interaction and quality of assignments as independent variables and the perceived learning effect of the seminars as the dependent variable.The response rate was 99%. Teacher performance (beta = 0.78) and group interaction (- 0.28) significantly influenced the perceived learning effect. The total effect of the quality of assignments (through effects on teacher performance and group interaction) was 0.47.The strong relationship between teacher performance and learning effect suggests that students rely strongly on their teachers. The negative effect of group interaction may reflect poor alignment of teaching and assessment and poor organisation of group processes. This should be further examined. Comparative studies on seminars are also recommended.

CONTEXT We addressed the assessment of professional behaviour in tutorial groups by investigating students' perceptions of the frequency and impact of critical incidents that impede this assessment and 5 factors underlying these critical incidents. METHODS A questionnaire asking students to rate the frequency and impact of 40 critical incidents relating to effective assessment of professional behaviour on a 5-point Likert scale was developed and sent to all undergraduate medical students in Years 2-4 of a 6-year undergraduate curriculum. RESULTS The response rate was 70% (n = 393). Important factors underlying critical incidents are: lack of effective interaction; lack of thoroughness; tutors' failure to confront students with unprofessional behaviour; lack of effort to find solutions, and lack of student motivation. Confirmatory factor analysis showed a good model fit. Because the relationship between frequency of occurrence and degree of impediment varies, the best information about the true impact of critical incidents and the underlying factors is provided by the product of frequency and degree of impediment. Frequency of occurrence remains stable and degree of impediment increases in Years 2-4. CONCLUSIONS The results of this study can be used to design and improve faculty development programmes aimed at improving assessment of professional behaviour. Training programmes should motivate tutors by providing background information as to why and how sound assessment of professional behaviour is to be performed and encourage tutors to confront students with and discuss all aspects of professional behaviour, as well as provide appropriate feedback.

Teachers' reflections are often narrowly focused on technical questions ('how to') and less on the underlying moral, political and emotional aspects of their functioning. However, for a better understanding of teaching practice it is important to uncover beliefs and values that usually remain implicit. Meeting with others is considered crucial for enhancing the quality of teachers' reflections. However, little is known about how any beneficial effects of such meetings are brought about. We explored the relationship between medical teachers' interactions and collaborative reflection processes during peer meetings. Five experienced teachers and a teacher trainer participated in the study. Three peer meetings were videotaped and transcribed. Teachers' interactions and collaborative reflective processes were analysed. The interactions promoted reflection not only on technical questions but also on moral, political, and emotional issues. 'Guiding/directing', 'proposing an alternative' and 'exploring an alternative' appeared to be the principal interactions. The results may be useful for teachers and trainers who are considering organising and/or improving peer meetings.

Introduction: There are few published studies that address the problem of dysfunctional tutorial groups. Most studies are restricted to student or faculty opinions separately and to speciec aspects affecting the tutorial group function. This study examined teacher and student perceptions of frequency and importance of problems observed in tutorial groups in a new PBL program. Methods: Tutors (n=30) and students in the second (n=75) and third (n=53) year completed a questionnaire at the beginning of the 1999 academic year. The questionnaire had 33 items grouped as seven ''factors'' related to tutor performance, feedback, assessment, educational resources, student performance, educational problems and external factors Results: The most important problems identieed were related to tutors (mainly in training aspects) and students (mainly in problem discussion). Students and feedback (quality) were the most frequent. There were statistically signiecant differences between tutors' and students' (higher) and between second and third year (higher) students' perceptions of different factors. Conclusions: (1) Marilia Medical School (FAMEMA) has problems in the tutorial group function mainly related to contributions of students and tutors. (2) Students' and tutors' opinions, as well as those of second and third year students, differ and therefore all need to be consulted to solve tutorial group problems. (3) It is necessary to develop a better student training program and also to improve the tutors training program. (4) There is a need for continued evaluation of problem-based learning at FAMEMA. We must look at perceptions of students from all years.

The aim of this study is to explore student's perceptions of incidents in tutorial groups and their perceptions of the tutor's role in these incidents. This study investigated the differences between three types of perceptions: the perceptions of the occurrence of critical incidents in tutorial groups, the perceptions of whether these incidents inhibit tutorial group functioning and the expectations students have of the role of the tutor with respect to these incidents. Variations in these student perceptions were also investigated for different training levels. The subjects consisted of a stratified random sample of 200 students from first, second, third and fourth year at the Medical School of the University of Maastricht. We used a questionnaire that consisted of a list of 36 statements and related descriptions of critical incidents in the tutorial group. Six potential success inhibitors (lack of elaboration, lack of interaction, unequal participation, lack of cohesion, difficult personalities and lack of motivation) were assumed to underlie the statements of the questionnaire. Students were asked to rate each incident on a five-point Likert scale for the three types of perceptions. The major finding of this study was that there are significant differences between the three types of student perceptions. We also found that there are significant differences between perceptions of students in each of the four academic years. We conclude that all potential success inhibitors play a role in explaining dysfunctional tutorial groups. Motivational influences seem to have a particularly strong impact on tutorial group function.

The tutor role in problem-based learning (PBL) has attracted the interest of many researchers and has led to an abundance of studies. This article reports on major trends in studies investigating the tutor during the past 10 years. Three major trends were observed by the authors while analysing the studies conducted: studies on the differential influence of content expert and non-content expert tutors on student achievement, studies on process variables, and studies on the relationship between tutor characteristics and differential contextual circumstances. The aim of this article is to summarize the main findings of the studies conducted so far within the three trends observed, to provide directions for educational practitioners and policy makers, and to suggest directions for future research questions. The studies included were selected by conducting a literature search in medical journals, which was complemented with the personal archives of the authors. The results of the studies conducted within the three trends of research have led to advanced insights in tutoring. The outcomes revealed that content expert tutors tend to use their subject-matter expertise more to direct the discussion in the tutorial group, whereas non-content expert tutors tend to use their process-facilitation expertise more to direct the tutorial group. Furthermore, a tutor's performance is not a stable characteristic but is partly situation specific. It is concluded that a tutor should both know how to deal with the subject matter expertise and should know how to facilitate the learning process. Faculty and policy makers should put substantial efforts into designing curricula and cases and developing tutors' skills by faculty development strategies that stimulate reflection. The research agenda should be driven more by modern educational theories of learning in which tutoring is a process aimed at stimulating constructive, self-directed, situated and collaborative learning by students. Furthermore, more qualitative studies should be conducted to gain better insights in teachers' conceptions about the tutor role and student learning to better understand their behaviours.

Morning reports offer opportunities for intensive work-based learning. In this controlled study, we measured learning processes and outcomes with the report of paediatric emergency room patients. Twelve specialists and 12 residents were randomised into four groups and discussed the same two paediatric cases. The groups differed in their presentation modality (verbal only vs. verbal + text) and the use of buzz groups (with vs. without). The verbal interactions were analysed for clinical reasoning processes. Perceptions of learning and judgment of learning were reported in a questionnaire. Diagnostic accuracy was assessed by a 20-item multiple-choice test. Combined bimodal presentation and buzz groups increased the odds ratio of clinical reasoning to occur in the discussion of cases by a factor of 1.90 (p = 0.013), indicating superior reasoning for buzz groups working with bimodal materials. For specialists, a positive effect of bimodal presentation was found on perceptions of learning (p

The study reported here examines student perceptions about the occurrence of critical incidents in tutorial groups across years of medical training. The study investigates the following research questions. (1) Which factors underlie the occurrence of critical incidents in the tutorial group? (2) How do students rate the incidents with respect to whether they occur in the tutorial groups? (3) Are there differences in scores on the factors identified across years of medical training? The subjects consisted of a stratified random sample of 200 students at the Medical School of the University of Maastricht. In general, the results of the confirmatory factor analyses indicate that a six-factor model showed a good fit. The results show that students frequently perceive lack of elaboration, lack of interaction and unequal participation in tutorial groups. For most of the factors (lack of elaboration, difficult personalities, lack of cohesion, and lack of motivation) the average scores differ significantly (p0.01) across the years.

textabstractThe Purpose of this study was to examine effects of group discussion of a medical problem on the comprehension of a subsequent problem-relevant text by first year medical students. Forty-eight first-year medical students were randomly assigned to one of two conditions: The experimental group discussed a problem of blood pressure regulation, where the control group discussed a problem of vision. Subsequently, all students studied a text on the physiology of blood pressure regulation. Finally, a free recall test was administered. Numbers of propositions accurately recalled were analyzed using analysis of variance (ANOVA). Students who discussed the blood pressure regulation problem recalled 25% more from the text than those who discussed the control problem. This difference was statistically significant. The present study represented the first truly randomized trial in the ecologically valid context of a medical curriculum. It demonstrated the positive effects of problem-based tutorial group discussion on the comprehension of text. It confirmed earlier findings from laboratory studies that problem-based learning, in addition to positive emotional and motivational long-term effects well-documented in the literature, also has positive effects on learning.

Item does not contain fulltext BACKGROUND: Teachers' belief in their ability to teach influences how much of the new knowledge and skills gained during faculty development (FD) programs are actually implemented at the workplace. AIM: To study the effect of a longitudinal FD program on the self-efficacy beliefs (SEB) of teachers of health professions using quasi-experimental methodology. METHODS: The SEB of 70 teachers of health professions enrolling for a longitudinal FD program at three sites in India and one site in South Africa and an equal number of comparable controls were measured using the "teacher efficacy belief systems-self" (TEBS-self) scale. The scale was re-administered at 6 and 12 months to both the groups. RESULTS: Teachers enrolled in the program had lower scores than controls at the beginning of the program but demonstrated a significant increase at 6 months with an effect size of 0.56. The 12-month scores demonstrated a further rise in the participating teachers. The control group maintained the scores but did not show any significant change either at 6 or at 12 months. CONCLUSION: Longitudinal FD program has positive effect on SEB of teachers.

Background: Clinical teachers use several different types of knowledge in the act of teaching. These include content knowledge (subject matter), knowledge of how to teach (pedagogy) and knowledge of learners (context). Most attention in faculty development has been on how to teach rather than what is taught. The quality of a teacher's subject matter knowledge is likely to be a critical determinant of how well a subject is presented, communicated and learned. We therefore set out to examine teachers' subject matter knowledge in the context of a general practice tutorial on grade 1 hypertension.Methods: This study is part of a larger study that employed a mixed method approach (concept mapping, phenomenological interviews and video-stimulated recall) to examine differences between clinical educators in subject matter knowledge, pedagogical knowledge and knowledge of the learning environment in the context of general practice education.Results: This paper presents the concept map data findings from the larger study as well as the parts of the phenomenological interviews that relate to subject matter knowledge and beliefs. We found that there were marked differences in the quality and elaborative structure of GP teachers' knowledge in the concept maps completed prior to the tutorials. These differences were also predictive of differences in the content presented to learners in tutorials. Teachers' beliefs about subject matter were also likely to have affected what they chose to teach about and how they presented it.Conclusions: Subject matter knowledge varies considerably between GP teachers in the context of a common and relatively simple tutorial. Differences in the quality of subject matter knowledge matter because they have a profound effect on what is learned and how it is learned. Faculty development for clinical educators needs to pay heed to the quality of subject matter knowledge in addition to its more common pedagogical focus.

Objective Visual expertise relies on perceptive as well as cognitive processes. At present, knowledge of these processes when diagnosing clinical cases mainly stems from studies with still pictures. Patient video cases constitute a dynamic and authentic, diagnostic challenge that may simulate seeing and diagnosing a patient in person. This study investigates visual attention and the concomitant cognitive processes of clinicians diagnosing authentic pediatric video cases. Methods A total of 43 clinicians with varying levels of expertise took part in this cross-sectional study. They diagnosed four brief video recordings of children: two with seizures and two with disorders imitating seizures. We used eye tracking to investigate time looking at relevant areas in the video cases and a concurrent think-aloud procedure to explore the associated clinical reasoning processes. Results More experienced clinicians were more accurate in visual diagnosis and spent more of their time looking at relevant areas. At the same time, they explored data less, yet they built and evaluated more diagnostic hypotheses. Interpretation This study adds a new perspective on medical expertise. More experienced clinicians (experts) focus better on relevant areas allowing them to explore data less and at the same time to build and evaluate more diagnostic hypotheses. The combination of effective visual search and the ability to effectively monitor for and evaluate different diagnostic options seems to characterize the experts in visual domains. (Less)

Background Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents. A more comprehensive overview of medical error in hospitals may be obtained by combining information from multiple sources. The WHO has developed the International Classification for Patient Safety (ICPS) in order to enable comparison of incident reports from different sources and institutions. Methods The aim of this paper was to provide a more comprehensive overview of medical error in hospitals using a combination of different information sources. Incident reports collected from IRS, patient complaints and retrospective chart review in an academic acute care hospital were classified using the ICPS. The main outcome measures were distribution of incidents over the thirteen categories of the ICPS classifier “Incident type”, described as odds ratios (OR) and proportional similarity indices (PSI). Results A total of 1012 incidents resulted in 1282 classified items. Large differences between data from IRS and patient complaints (PSI = 0.32) and from IRS and retrospective chart review (PSI = 0.31) were mainly attributable to behaviour (OR = 6.08), clinical administration (OR = 5.14), clinical process (OR = 6.73) and resources (OR = 2.06). Conclusions IRS do not capture all incidents in hospitals and should be combined with complementary information about diagnostic error and delayed treatment from patient complaints and retrospective chart review. Since incidents that are not recorded in IRS do not lead to remedial and preventive action in response to IRS reports, healthcare centres that have access to different incident detection methods should harness information from all sources to improve patient safety.

Background: Patient safety has become an important topic over the last decade and has also been increasingly implemented in the undergraduate curriculum. However, the best timing and method of teaching still remains to be decided. Aims: To develop and evaluate a patient safety course for final-year students. The course is based on reflective learning and personal experiences to improve the transfer of theory into practice. Methods: We performed a mixed method evaluation study of the course. An evaluation questionnaire and the number of completed incident report cards were analyzed using descriptive statistics. Focus groups, organized two and four weeks after the course, were analyzed using template analysis; the Theory of Planned Behaviour (TPB) was used to interpret the results. Results: Students found the course overall instructive and reacted positively towards many elements of the course. Focus group analysis showed that an increase in knowledge about patient safety topics resulted in a change of attitudes towards these subjects and in an increase in awareness of patient safety. This influenced students' behavioral intention and their behavior. Conclusions: A course based on students' personal experiences enables them to transfer theory on patient safety issues into their own practice and has an effect on their awareness, attitudes and behavior. This could have a large impact on their future role as resident.

Given the changes in society we are experiencing, the increasing focus on patient-centred care and acknowledgement that medical education including professionalism issues needs to continue not only in the residency programmes but also throughout the doctors career, is not surprising. Although most of the literature on professionalism pertains to learning and teaching professionalism issues, addressing unprofessional behaviour and related patient safety issues forms an alternative or perhaps complementary approach. This article describes the possibility of selecting applicants for a medical school based on personality characteristics, the attention to professional lapses in contemporary undergraduate training, as well as the magnitude, aetiology, surveillance and methods of dealing with reports of unprofessional behaviour in postgraduate education and CME.

Background: Resuscitation outcomes are related to care delivered by 'first responders', even for hospitalized patients. Third year medical students (clinical clerks) at McGill University are trained and certified in Advanced Cardiac Life Support (ACLS) for critically ill adult patients, but receive only minimal instruction, in the form of a brief introductory lecture, on paediatric life support. Methods: We developed an interactive, case-based 4-h Paediatric Resuscitation Course based on the objectives and teaching methods of the Pediatric Advanced Life Support (PALS) course. Objectives were tailored to an appropriate level for medical students through the consensus of the two content-expert authors and two external expert physician-educators. Students completed equivalent pre and post course multiple-choice exams, using questions selected from the PALS course. In order to minimize 'guessing', subjects were penalized for incorrect answers. Upon completion of the course, students were anonymously surveyed on the perceived educational value of the resuscitation course. Results: 49 subjects voluntarily participated, in groups of 6-8 at a time, with 47 subjects completing the study protocol. Students' test scores significantly increased from the pre to post test (12.65/22 vs. 17.70/22; p

OBJECTIVE: The goal was to determine whether the diagnostic accuracy of nonexperts in selected learning environments would improve with the use of patient video cases (PVCs). METHODS: We designed a stepwise, team-based, learning approach with a (1) text-based patient presentation, (2) first review of a PVC, (3) small-group discussion, (4) second review of a PVC, and (5) large-group discussion and listening to think-aloud modeling by a content expert. Four pediatric neurology PVCs were analyzed by 44 physicians. After each step, the diagnostic accuracy was assessed with a questionnaire with open-ended questions measuring the frequency of relevant diagnoses and clinical diagnostic reasoning processes. RESULTS: The first review of the PVC was followed by a large number of relevant clinical diagnostic reasoning processes. Small-group discussions and listening to a think-aloud procedure with an expert were particularly effective in increasing the diagnostic accuracy of the nonexperts. CONCLUSIONS: The diagnostic accuracy of nonexperts was clearly enhanced by interaction in small-group discussions and subsequent listening to a think-aloud procedure with a content expert. Learning through PVCs in clinical settings thus is improved through the interactive participation of junior and senior clinicians. Such an environment (a “virtual examination room”) may be introduced at grand rounds, case conferences, or morning rounds, to stimulate the development of diagnostic accuracy in nonexperts.

Recommendations in the literature concerning measures to address the challenges to professionalism have converged on the establishment of an education community, on a structured curriculum dealing with professionalism, on developing programs for role modelling and mentoring, and on attention to the assessment of professional conduct. The interventions in the field of medical education appear central among these efforts, since it is during medical school that the template for professional conduct in medicine is primarily learned. This article attempts to provide a more in-depth discussion of the goals, purposes and current factors influencing teaching and learning professional behaviour in the medical school curriculum and the residency programs.

This paper is the fourth article in a series on Professionalism and provides an overview of current methods used for teaching and learning about professionalism. The questions "whether" and "how" professionalism can be placed in the formal medical school curricula are addressed, and the informal learning related to professionalism reviewed.

The concept of professionalism has undergone major changes over the millennia in general and the last century specifically. This article, the first in a series of articles in this Journal on professionalism, attempts to provide the reader with a historical overview of the evolution of the concept of professionalism over time. As a result of these changes, medical school curricula, and contemporary specialist training programs are increasingly becoming competence based, with professionalism becoming an integral part of a resident's training and assessment program.

Objective To explore student perceptions of factors contributing to the effectiveness of discussions in the reporting phase of the problem-based learning (PBL) process, where students report and synthesise the results of self-study. Methods Forty-eight Year 1 and 2 medical students participated in 6 focus group interviews about the characteristics of effective group discussions and possible improvements. The data were analysed qualitatively in several stages. Results The analysis yielded 4 main characteristics of effective discussions: asking for, giving and receiving explanations; integrating and applying knowledge; discussing differences with regard to learning content, and guiding and monitoring the content and the group process of the discussion. Integrating and applying knowledge included structuring, relating and summarising information and providing examples from practice. Discussing different opinions included discussing a variety of literature resources and disagreements. The main learning effects mentioned by the students were retention, understanding, integration and application of knowledge. Conclusions Students have clear ideas about what promotes effective discussions during the reporting phase. Their PBL experience has provided them with some insights that are in line with theory and research on collaborative learning. Future research should examine differences between student and tutor perceptions of the quality of discussions. Introductions to PBL for students and tutors should include training in asking open but focused questions, supporting explanations with arguments and dealing with conflicts about learning content. Tutors should be trained in giving effective and personal feedback. Collaborative creation of external knowledge representations (i.e. concept maps) should be advocated, as should variety of literature resources.

BACKGROUND Whether teaching portfolios achieve their aim of stimulating teachers' professional development is favourably affected by the incorporation of a balanced structure and effective social interactions, such as coaching. We explored teachers' experiences with a teaching portfolio that was structured by teaching roles, portfolio assignments and conversation protocols. The related social interactions consisted of meetings with peers and personal coaches. Teachers' and coaches' opinions were sought about the benefits and the enabling and disabling factors of the portfolio structure and the social interactions involved. METHOD Five teachers and their personal coaches were individually interviewed about their experiences with the portfolio. Protocols were analysed using a top-down strategy. RESULTS The teaching roles were helpful in analysing teaching, but the assignments and the conversation protocols were too detailed and directive. The social interactions were perceived as very valuable for professional development, particularly the meetings with personal coaches. CONCLUSIONS The portfolio structure and social interactions, especially personal coaching, appeared to be helpful for teachers in analysing their teaching practice. The assignments and protocols, however, were too detailed and directive. This may be resolved by using assignments and conversation protocols more flexibly and enabling adjustment to personal learning needs. The high appreciation of personal coaching might be related to the freedom for teachers to choose their own coach. The results can be used by portfolio designers as guidelines for how to achieve a balanced structure and effective social interactions and how these might be combined to increase the benefits of working with a portfolio to teachers.

An instrument has been developed to provide tutors with feedback about their performance in problem-based tutorial groups. This questionnaire consists of 33 statements reflecting the behaviour of the tutor in the tutorial group when students analyse the case and generate learning issues and the behaviour of the tutor when students report back to the tutorial group about their self-study. The statements are grouped on theoretical dimensions found in the literature about co-operative learning and problem-based learning. This study focuses on the validity and the reliability of this instrument. Confirmatory factor analysis showed that a four-factor model showed a weak fit, whereas each separate factor fitted the data reasonably well. The four factors are: (1) elaboration; (2) directing the learning process; (3) integration of knowledge and (4) stimulating interaction and individual accountability. These factors were strongly correlated with the overall judgement of the tutor at the end of the unit, so the concurrent validity of this instrument was high. Generalizability studies indicated that the rating scales provide reliable information with a sample size of student responses falling within the range of real tutorial group sizes. The results of this study show that the instrument for providing tutors with feedback is valid and reliable. This questionnaire can be used in staff development activities and also provides needs assessment for faculty development.

Two experiments assessed effects of activation of prior knowledge through small-group discussion. Subjects were given a description of natural phenomena and were asked to elaborate on possible explanations for them. In Experiment 1, small groups of subjects were presented with a problem describing the behavior of a blood cell in pure water and in a salt solution. No additional text was studied. The experimental subjects produced more than twice as many propositions about osmosis (i.e. the biological process explaining the blood cell's behavior) as a control group produced. Experiment 2 investigated effects of problem analysis on subsequent text processing for subjects with imprecise prior knowledge (novices) and subjects with precise knowledge (experts). Recall of the text showed considerable facilitative effects of problem analysis. Results are explained in terms of faster accessibility of prior knowledge and better integration of new information into explanatory models that may exist before, or are actively constructed during, problem analysis. Attempts to understand the physical world involve the use of cognitive structures that represent mechanisms or principles underlying the phenomena observed. These cognitions may vary from highly sophisticated to quite naive. They may emerge as the result of formal education but often are constructed "spontaneously" while a person is experiencing the phenomena concerned. Take thunder and lightning. By scientists, this natural phenomenon is interpreted in terms of large differences in electrical potential between clouds charged with static electricity and the earth. Young children however, generally favor explanations involving the clash of clouds, and in earlier centuries thunder was attributed to the rage of the gods. These naive "mental models" are, like the models of science, not merely descriptive of what is going on in the outer world. They are truly "explanatory," because they clarify why the world is as it is. In addition, these conceptions can be considered models because they usually consist of a set of concepts connected by causal links that help to interpret the phenomena concerned in terms of the underlying structure of these phenomena (Clement, 1979; Gentner & Stevens, 1983).

Problem-based small-group discussions are the cornerstone of health sciences education at the University of Limburg (The Netherlands). In each of three courses, fifteen discussion groups of about eight students were randomly assigned a staff-tutor (control condition) or student-tutor (experimental condition).

Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is referred to as workplace learning, a complex system in which various factors influence what is being learned and how. A theory that can highlight potential difficulties in this complex learning system about patient safety is activity theory. Thirty-four final year undergraduate medical students participated in four focus groups about their experiences concerning patient safety. Using activity theory as analytical framework, we performed constant comparative thematic analysis of the focus group transcripts to identify important themes. We found eight general themes relating to two activities: learning to be a doctor and delivering safe patient care. Simultaneous occurrence of these two activities can cause contradictions. Our results illustrate the complexity of learning about patient safety at the workplace. Students encounter contradictions when learning about patient safety, especially during a transitional phase of their training. These contradictions create potential learning opportunities which should be used in education about patient safety. Insight into the complexities of patient safety is essential to improve education in this important area of medicine.