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The role and responsibilities of pharmacists have changed considerably over the past decade. Activities like independent prescribing, administering vaccines, and public health screening have fundamentally changed due to what the public expects of pharmacists - and what pharmacists think and believe about their own roles and value contributions to the healthcare system. This thesis questioned the significant value placed on the clinical knowledge, roles, and functions in pharmacy education, coupled with the documented challenges associated with enacting these roles and functions in practice. Alongside, there were conversations about professional identity formation in health professions education, with particular emphasis on the role of professional education and training in guiding identity development. This led to the primary purpose of this thesis, which was to identify discourses (institutionalized ideas, norms, and practices that contribute to the socio-cultural dimensions of the learning environment) at play in pharmacy education and practice that pharmacy students and pharmacists engage with when constructing and performing their professional identities. We aimed to uncover the messages and cues that these discourses convey about what it means to be a pharmacist in the 21st century.

Workplace assessments play a central role in medical further education. Workplace assessments serve two functions: to provide feedback to the trainee physician to promote learning and to enable decisions about their performance and progress. Our studies were conducted at the general practitioner training courses in Maastricht, Nijmegen and Leiden. This shows that users' perceptions of workplace assessments can differ and play a role in its use and interpretation. Also, interactions between users from inside and outside the workplace can influence workplace assessments. For example, at the start of the training, educators base their decision to entrust patients to the trainee physician more on their generic qualities (e.g. asking for help in good time) than on estimated clinical skills. Practical observations of doctors-in-training are also mainly performed because educators believe that this is expected of them, for example by patients, the doctor-in-training or the training institute. The use and purpose of field observations is rarely a topic of discussion between educator and trainee physician. As a result, learning opportunities may be missed. Being aware and discussing one's own views and according them with those of other users can increase the yield of workplace assessments.

Training of doctors has recently been modernized to become more individualized and learner-centered. Teaching hospitals are required to monitor and improve the quality of their training with the assumption that this will also benefit patient care. This thesis tests this assumption by studying the associations between indicators of training quality (learning climate and teaching quality) and health care delivery in teaching hospitals in the Netherlands across a range of outcomes and specialties. It concludes that what’s good for the doctor may not be good for the patient. Optimizing both training and quality of care rests on our understanding of the nature of this relationship.

Poor doctor-patient communication is a global concern. Much effort and finances are invested in communication skills training in medical schools around the world with only marginal effects on clinical communication in daily practice. This thesis addresses the problem from an educational view-point. It analyses why the current forms of training do not establish enough transfer of learned skills from training to daily practice. Moreover it provides insight in the learning process itself. It appears that residents/clinicians learn and improve their communication along five phases: confrontation, becoming aware, seeking alternatives, personalisation and internalisation & integration. Van den Eertwegh provides evidence-based recommendations that lead to more effective forms of training and learning resulting in more awareness and better integration of doctor-patient communication in the daily work of the busy physician.

Nowadays, assessing physicians’ professional performance is very important. An oft-used method to assess physicians’ performance are questionnaires. These questionnaires, which consist of scores based on statements about performance, provide physicians with feedback from different colleagues, i.e. so-called 360° feedback. Since January 2020, medical specialists are required to collect this feedback, without it they cannot reregister as a specialist. In this thesis, the validity of these questionnaires is examined.In order to see if physicians’ performance improves after collecting feedback, how the scores change over time was researched. It was found that 50% of the physicians improved their scores, and it seems that the improvement is influenced by how the physicians gauge their own performance. Physicians who assess their own performance higher than their colleagues, seem to improve less or not at all. The results of the research suggest that collecting 360° feedback should not be the only tool used to provide insight into one’s own performance.

Clinical knowledge is rapidly advancing. Medical professionals need to update their knowledge autonomously throughout their lives. “Self-regulated learning” has come to be an important competency in the lives of medical professionals. Probably because of the teacher-centred educational culture in East Asia, including Japan where this research was conducted, passive and less-strategic learning still prevails. The central theme of this thesis is how to address the challenge of self-regulated learning by medical students in teacher-centred contexts. We explored contextual attributes which could foster self-regulated learning, and established a practical scheme to trigger self-regulated learning by applying these contextual attributes to it. The results showed that learning contexts which allow for self-reflection based on individual identity with concrete future self-images promote self-regulated learning skills. “Professional identity formation,” defined as the formation of a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalised, might play a pivotal role in fostering self-regulated learning in a teacher-centred context. Funded by JSPS Kakenhi and the Japan Medical Education Foundation

Feedback from multiple sources is needed to improve performance and engage in continuous self-improvement. In medical education, it has traditionally been a unidirectional teacher to learner conversation. Recent research suggests that sociocultural factors such as relationships and institutional culture play a central role in the quality of feedback exchanges and impact on recipient behaviour. Our research further advances these insights through exploration of perspectives regarding the influence of cultural factors on feedback. We recommend a dynamic learner-initiated and teacher-facilitated bidirectional exchange of feedback, targeting learner behaviour change. Institutions should promote a feedback culture that normalises strengths as well as deficiencies at all levels, provides a safe space to discuss errors, and promotes longitudinal relationships, feedback seeking, performance observation, and a growth mind-set. In summary, the pendulum of feedback should swing from recipes for giving feedback to relationships for fostering meaningful conversations.

Healthcare simulation training has spread worldwide leading to a search for its optimal effectiveness. Instructional Design (ID) guidelines derive from sound learning theories and can be used to improve simulation training design. This thesis aimed to explore the impact of such guidelines for postpartum hemorrhage (PPH) simulation training. PPH is the world-leading cause of maternal mortality and has similar management to other healthcare high-risk situations. The findings show that the application of ID guidelines for designing PPH simulation training leads to better learning, transfer of learning and patient outcomes. Unfortunately, existing PPH simulation training still poorly adheres to ID guidelines.

Clinical reasoning is generally considered a decisive component of nearly everything doctors do in practice. There are indications that clinical reasoning is not well taught at present. So-called Virtual Patients (VP) are especially suited to foster learning of clinical reasoning. Virtual Patients are online cases in which the learner takes on the role of physician, has to make all decisions him/herself and receives feedback on these decisions. This dissertation examines how to improve the design and implementation of Virtual Patients to foster learning, especially of clinical reasoning. Our results provide concrete advice on how to accomplish that and are in line with current theories and insights outside of VP research.

The results of this study demonstrate the suitability of Computer Supported Collaborative Learning (CSCL) as a learning environment for collaborative learning by medicine students during clinical clerkships. The results show what internet has to offer to students who need to study individually at a distance. It was concluded that a CSCL learning environment is a promising tool for medicine students in terms of enabling them to give feedback to each other on their respective learning tasks and to adjust these tasks in a clinical workplace learning setting. Due to the increase in technological developments and the digitalisation of society, distance learning becomes more and more important for universities and institutions of higher education. That is why the findings of this dissertation are important for universities to which the digitalisation of education, the provision of online learning possibilities and the ability to be connected to the university 24 hours a day, 7 days a week are particularly relevant.

The focus is design of simulation and choice of setting in simulation-based medical education. Simulation means a person, device, or set of conditions which attempts to present education authentically. The innovative value can be boiled down to this pragmatic conclusion when looking at outcome on individual and team learning: “You can simulate anywhere”. Our recommendation for institutions planning simulation is that they can conduct simulation in all kinds of settings and that they can decide based on the level of feasibility. However, to achieve organisational learning, it is recommended to occasionally conduct announced or unannounced in situ simulation, which means simulation in the actual patient-care unit.

This dissertation examines the teamwork between medical specialists that train resident physicians. The way these specialists function as a team of academic trainers can be improved, certainly given the fact that they tend to be too task-oriented. The formal educator is too often seen as a super-teacher, who takes on the majority of the teaching load. There is little room for giving feedback, resolving conflicts, and working towards a collective ambition. An effective medical training group works towards structurally improving postgraduate medical education with a secondary aim of improving patient care. This dissertation recommends developing a validated digital evaluation tool that medical specialists can use to evaluate teamwork in training groups.

Medical trainees are assessed performing clinical tasks but the examiners’ ratings can be highly variable. It is assumed that examiners assessing the same performance should form similar judgments and provide similar ratings. As such, the psychometric models currently used to analyze the ratings assume there is a single point of consensus. This research, however, found multiple clusters of consensus within the variable assessments provided by examiners for a single performance. This finding was consistent across two samples of participants and two different methodologies. Finding more than one point of consensus challenges the use of psychometric models to analyze examiners’ ratings.

The research aims to understand how student react to summative or formative assessment within the clinical setup and to explore factors that direct the students towards deep learning approaches. This includes knowledge integration, writing summaries, self-testing, clinical problem solving and safe patient management. The conclusion is that several intrinsic and extrinsic assessment factors have been found to affect students' learning and learning approaches. Many of these factors were theoretically proposed but few of them have been already researched.

The applications of statistics in a daily and professional context are numerous, but there are even more examples of faulty applications of statistics in such a context. Given the important role statistics play in research, politics, policy etc. it is of great importance that students and professional develop a good understanding of statistics. This requires a structured and phased approach. Characteristic for this approach is a fading degree of guidance by the teacher in consecutive phases, while the possibility of getting feedback on learning results continues to exist.