Showing papers in "Medical Education in 2014"

A critical review of simulation-based mastery learning with translational outcomes.

Abstract: Objectives: This article has two objectives. Firstly, we critically review simulation-based mastery learning (SBML) research in medical education, evaluate its implementation and immediate results, and document measured downstream translational outcomes in terms of improved patient care practices, better patient outcomes and collateral effects. Secondly, we briefly address implementation science and its importance in the dissemination of innovations in medical education and health care. Methods: This is a qualitative synthesis of SBML with translational (T) science research reports spanning a period of 7 years (2006-2013). We use the 'critical review' approach proposed by Norman and Eva to synthesise findings from 23 medical education studies that employ the mastery learning model and measure downstream translational outcomes. Results: Research in SBML in medical education has addressed a range of interpersonal and technical skills. Measured outcomes have been achieved in educational laboratories (T1), and as improved patient care practices (T2), patient outcomes (T3) and collateral effects (T4). Conclusions: Simulation-based mastery learning in medical education can produce downstream results. Such results derive from integrated education and health services research programmes that are thematic, sustained and cumulative. The new discipline of implementation science holds promise to explain why medical education innovations are adopted slowly and how to accelerate innovation dissemination.

Debriefing for Technology-Enhanced Simulation: A Systematic Review and Meta-Analysis

Abstract: Objectives: Debriefing is a common feature of technology-enhanced simulation (TES) education However, evidence for its effectiveness remains unclear We sought to characterise how debriefing is reported in the TES literature, identify debriefing features that are associated with improved outcomes, and evaluate the effectiveness of debriefing when combined with TES Methods: We systematically searched databases, including MEDLINE, EMBASE and Scopus, and reviewed previous bibliographies for original comparative studies investigating the use of TES with debriefing in training health care providers Reviewers, in duplicate, evaluated study quality and abstracted information on instructional design, debriefing and outcomes Effect sizes (ES) were pooled using random-effects meta-analysis Results: From 10 903 potentially eligible studies, we identified 177 studies (11 511 learners) that employed debriefing as part of TES Key characteristics of debriefing (eg duration, educator presence and characteristics, content, structure/method, timing, use of video) were usually incompletely reported A meta-analysis of four studies demonstrated that video-assisted debriefing has negligible and non-significant effects for time skills (ES = 010) compared with non-video-assisted debriefing Meta-analysis demonstrated non-significant effects in favour of expert modelling with short debriefing in comparison with long debriefing (ES range = 021-074) Among studies comparing terminal with concurrent debriefing, results were variable depending on outcome measures and the context of training (eg medical resuscitation versus technical skills) Eight additional studies revealed insight into the roles of other debriefing-related factors (eg multimedia debriefing, learner-led debriefing, debriefing duration, content of debriefing) Among studies that compared simulation plus debriefing with no intervention, pooled ESs were favourable for all outcomes (ES range = 028-216) Conclusions: Limited evidence suggests that video-assisted debriefing yields outcomes similar to those of non-video-assisted debriefing Other debriefing design features show mixed or non-significant results As debriefing characteristics are usually incompletely reported, future debriefing research should describe all the key debriefing characteristics along with their associated descriptors

Medical student depression, anxiety and distress outside North America: a systematic review

Abstract: Context North American medical students are more depressed and anxious than their peers. In the UK, the regulator now has responsibility for medical students, which may potentially increase scrutiny of their health. This may either help or hinder medical students in accessing appropriate care. The prevalences of anxiety, depression and psychological distress in medical students outside North America are not clear. A better understanding of the prevalence of, risk factors for and results of psychological distress will guide the configuration of support services, increasingly available for doctors, for medical students too. Objectives The aim of this study was to examine the prevalences of depression, anxiety and psychological distress in students in medical schools in the UK, Europe and elsewhere in the English-speaking world outside North America. Methods A systematic review was conducted using search terms encompassing psychological distress amongst medical students. OvidSP was used to search the following databases: Ovid MEDLINE (R) from 1948 to October 2013; PsycINFO from 1806 to October 2013, and EMBASE from 1980 to October 2013. Results were restricted to medical schools in Europe and the English-speaking world outside North America, and were evaluated against a set of inclusion criteria including the use of validated assessment tools. Results The searches identified 29 eligible studies. Prevalences of 7.7–65.5% for anxiety, 6.0–66.5% for depression and 12.2–96.7% for psychological distress were recorded. The wide range of results reflects the variable quality of the studies. Almost all were cross-sectional and many did not mention ethical approval. Better-quality studies found lower prevalences. There was little information on the causes or consequences of depression or anxiety. Conclusions Prevalences of psychological distress amongst medical students outside North America are substantial. Future research should move on from simple cross-sectional studies to better-quality longitudinal work which can identify both predictors for and outcomes of poor mental health in medical students.

Interprofessional education in allied health: a systematic review.

Abstract: Objectives During the past decade, several studies have systematically reviewed interprofessional education (IPE), but few have inclusively reviewed this literature. None has focused primarily on IPE in allied health, despite differences in recruitment and socialisation across the health professions. This systematic review seeks to uncover the best approach to pre-licensure, university-based allied health IPE to determine which aspects require modification in which contexts to provide optimal learning experiences. Methods A systematic search of 10 databases was conducted for articles published in English, between January 1998 and January 2013. Studies were included if they used quantitative or qualitative methodologies to report on the outcomes associated with IPE in allied health. Two independent reviewers identified studies that met the inclusion criteria, critically appraised the included studies and extracted data relating to the effectiveness of IPE in allied health. Data were synthesised narratively to address the study aims. Results Large gaps – relating to methods, theory and context – remain within this body of literature. Studies measured students' attitudes and understanding of other health professional roles, teamwork and knowledge in response to IPE interventions using patient scenarios, lectures and small-group work. Differences in power and curriculum placement were described as factors affecting IPE effectiveness. Conclusions Evaluation remains the primary aim within this literature. Few studies use theory, take an inductive approach to understanding the processes behind IPE or include detailed participant descriptions. Therefore, we suggest that IPE research is currently caught in an epistemological struggle, between assumptions underpinning biomedical and health science research, and those underpinning education studies. As part of a systems approach to understanding interprofessional socialisation, we call for researchers to take a realistic approach to evaluation that is inclusive of, and responsive to, contextual factors to explore how IPE leads to improved long-term outcomes in differing circumstances.

Seeing the 'black box' differently: assessor cognition from three research perspectives.

Abstract: Context Performance assessments, such as workplace-based assessments (WBAs), represent a crucial component of assessment strategy in medical education. Persistent concerns about rater variability in performance assessments have resulted in a new field of study focusing on the cognitive processes used by raters, or more inclusively, by assessors. Methods An international group of researchers met regularly to share and critique key findings in assessor cognition research. Through iterative discussions, they identified the prevailing approaches to assessor cognition research and noted that each of them were based on nearly disparate theoretical frameworks and literatures. This paper aims to provide a conceptual review of the different perspectives used by researchers in this field using the specific example of WBA. Results Three distinct, but not mutually exclusive, perspectives on the origins and possible solutions to variability in assessment judgements emerged from the discussions within the group of researchers: (i) the assessor as trainable: assessors vary because they do not apply assessment criteria correctly, use varied frames of reference and make unjustified inferences; (ii) the assessor as fallible: variations arise as a result of fundamental limitations in human cognition that mean assessors are readily and haphazardly influenced by their immediate context, and (iii) the assessor as meaningfully idiosyncratic: experts are capable of making sense of highly complex and nuanced scenarios through inference and contextual sensitivity, which suggests assessor differences may represent legitimate experience-based interpretations. Conclusions Although each of the perspectives discussed in this paper advances our understanding of assessor cognition and its impact on WBA, every perspective has its limitations. Following a discussion of areas of concordance and discordance across the perspectives, we propose a coexistent view in which researchers and practitioners utilise aspects of all three perspectives with the goal of advancing assessment quality and ultimately improving patient care.

What is reflection? A conceptual analysis of major definitions and a proposal of a five-component model

Abstract: Context Although reflection is considered a significant component of medical education and practice, the literature does not provide a consensual definition or model for it. Because reflection has taken on multiple meanings, it remains difficult to operationalise. A standard definition and model are needed to improve the development of practical applications of reflection. Objectives This study was conducted in order to identify, explore and analyse the most influential conceptualisations of reflection, and to develop a new theory-informed and unified definition and model of reflection. Methods A systematic review was conducted to identify the 15 most cited authors in papers on reflection published during the period from 2008 to 2012. The authors’ definitions and models were extracted. An exploratory thematic analysis was carried out and identified seven initial categories. Categories were clustered and reworded to develop an integrative definition and model of reflection, which feature core components that define reflection and extrinsic elements that influence instances of reflection. Results Following our review and analysis, five core components of reflection and two extrinsic elements were identified as characteristics of the reflective thinking process. Reflection is defined as the process of engaging the self (S) in attentive, critical, exploratory and iterative (ACEI) interactions with one's thoughts and actions (TA), and their underlying conceptual frame (CF), with a view to changing them and a view on the change itself (VC). Our conceptual model consists of the defining core components, supplemented with the extrinsic elements that influence reflection. Conclusions This article presents a new theory-informed, five-component definition and model of reflection. We believe these have advantages over previous models in terms of helping to guide the further study, learning, assessment and teaching of reflection.

Reflections: an inquiry into medical students' professional identity formation

Abstract: Context Professional identity formation plays a crucial role in the transition from medical student to doctor. At McMaster University, medical students maintain a portfolio of narrative reflections of their experiences, which provides for a rich source of data into their professional development. The purpose of this study was to understand the major influences on medical students’ professional identity formation. Methods Sixty-five medical students (46 women; 19 men) from a class of 194 consented to the study of their portfolios. In total, 604 reflections were analysed and coded using thematic narrative analysis. The codes were merged under subthemes and themes. Common or recurrent themes were identified in order to develop a descriptive framework of professional identity formation. Reflections were then analysed longitudinally within and across individual portfolios to examine the professional identity formation over time with respect to these themes. Results Five major themes were associated with professional identity formation in medical students: prior experiences, role models, patient encounters, curriculum (formal and hidden) and societal expectations. Our longitudinal analysis shows how these themes interact and shape pivotal moments, as well as the iterative nature of professional identity from the multiple ways in which individuals construct meaning from interactions with their environments. Conclusions Our study provides a window on the dynamic, discursive and constructed nature of professional identity formation. The five key themes associated with professional identity formation provide strategic opportunities to enable positive development. This study also illustrates the power of reflective writing for students and tutors in the professional identity formation process.

Sociomateriality in medical practice and learning: attuning to what matters

Abstract: Context In current debates about professional practice and education, increasing emphasis is placed on understanding learning as a process of ongoing participation rather than one of acquiring knowledge and skills. However, although this socio-cultural view is important and useful, issues have emerged in studies of practice-based learning that point to certain oversights. Methods Three issues are described here: (i) the limited attention paid to the importance of materiality – objects, technologies, nature, etc. – in questions of learning; (ii) the human-centric view of practice that fails to note the relations among social and material forces, and (iii) the conflicts between ideals of evidence-based standardised models and the sociomaterial contingencies of clinical practice. Discussion It is argued here that a socio-material approach to practice and learning offers important insights for medical education. This view is in line with a growing field of research in the materiality of everyday life, which embraces wide-ranging families of theory that can be only briefly mentioned in this short paper. The main premise they share is that social and material forces, culture, nature and technology, are enmeshed in everyday practice. Objects and humans act upon one another in ways that mutually transform their characteristics and activity. Examples from research in medical practice show how materials actively influence clinical practice, how learning itself is a material matter, how protocols are in fact temporary sociomaterial achievements, and how practices form unique and sometimes conflicting sociomaterial worlds, with diverse diagnostic and treatment approaches for the same thing. Conclusions This discussion concludes with implications for learning in practice. What is required is a shift from an emphasis on acquiring knowledge to participating more wisely in particular situations. This focus is on learning how to attune to minor material fluctuations and surprises, how to track one's own and others’ effects on ‘intra-actions’ and emerging effects, and how to improvise solutions.

Emotional intelligence in medical education: a critical review.

Abstract: Context Emotional intelligence (EI) is a term used to describe people's awareness of, and ability to respond to, emotions in themselves and other people. There is increasing research evidence that doctors’ EI influences their ability to deliver safe and compassionate health care, a particularly pertinent issue in the current health care climate. Objectives This review set out to examine the value of EI as a theoretical platform on which to base selection for medicine, communication skills education and professionalism. Methods We conducted a critical review with the aim of answering questions that clinical educators wishing to increase the focus on emotions in their curriculum might ask. Results Although EI seems, intuitively, to be a construct that is relevant to educating safe and compassionate doctors, important questions about it remain to be answered. Research to date has not established whether EI is a trait, a learned ability or a combination of the two. Furthermore, there are methodological difficulties associated with measuring EI in a medical arena. If, as has been suggested, EI were to be used to select for medical school, there would be a real risk of including and excluding the wrong people. Conclusions Emotional intelligence-based education may be able to contribute to the teaching of professionalism and communication skills in medicine, but further research is needed before its wholesale adoption in any curriculum can be recommended.

Learning culture and feedback: an international study of medical athletes and musicians

Abstract: Objectives Feedback should facilitate learning, but within medical education it often fails to deliver on its promise. To better understand why feedback is challenging, we explored the unique perspectives of doctors who had also trained extensively in sport or music, aiming to: (i) distinguish the elements of the response to feedback that are determined by the individual learner from those determined by the learning culture, and (ii) understand how these elements interact in order to make recommendations for improving feedback in medical education. Methods Using a constructivist grounded theory approach, we conducted semi-structured interviews with 27 doctors or medical students who had high-level training and competitive or performance experience in sport (n = 15) or music (n = 12). Data were analysed iteratively using constant comparison. Key themes were identified and their relationships critically examined to derive a conceptual understanding of feedback and its impact. Results We identified three essential sources of influence on the meaning that feedback assumed: the individual learner; the characteristics of the feedback, and the learning culture. Individual learner traits, such as motivation and orientation toward feedback, appeared stable across learning contexts. Similarly, certain feedback characteristics, including specificity, credibility and actionability, were valued in sport, music and medicine alike. Learning culture influenced feedback in three ways: (i) by defining expectations for teachers and teacher–learner relationships; (ii) by establishing norms for and expectations of feedback, and (iii) by directing teachers' and learners' attention toward certain dimensions of performance. Learning culture therefore neither creates motivated learners nor defines ‘good feedback’; rather, it creates the conditions and opportunities that allow good feedback to occur and learners to respond. Conclusions An adequate understanding of feedback requires an integrated approach incorporating both the individual and the learning culture. Our research offers a clear direction for medicine's learning culture: normalise feedback; promote trusting teacher–learner relationships; define clear performance goals, and ensure that the goals of learners and teachers align.

Methods of teaching medical trainees evidence-based medicine: a systematic review.

Abstract: Context The principles of evidence-based medicine (EBM) provide clinicians with the ability to identify, source, appraise and integrate research evidence into medical decision making. Despite the mantra of EBM encouraging the use of evidence to inform practice, there appears little evidence available on how best to teach EBM to medical trainees. A systematic review was performed to identify what type of educational method is most effective at increasing medical trainees' competency in EBM. Methods A systematic review of randomised controlled trials (RCTs) was performed. Electronic searches were performed across three databases. Two reviewers independently searched, extracted and reviewed the articles. The quality of each study was assessed using the Cochrane Collaboration's risk of bias assessment tool. Results In total, 177 citations were returned, from which 14 studies were RCTs and examined for full text. Nine of the studies met the inclusion criteria and were included in this review. Learner competency in EBM increased post-intervention across all studies. However, no difference in learner outcomes was identified across a variety of educational modes, including lecture versus online, direct versus self-directed, multidisciplinary versus discipline-specific groups, lecture versus active small group facilitated learning. Conclusions The body of evidence available to guide educators on how to teach EBM to medical trainees is small, albeit of a good quality. The major limitation in assessing risk of bias was the inability to blind participants to an educational intervention and lack of clarity regarding certain aspects within studies. Further evidence, and transparency in design, is required to guide the development and implementation of educational strategies in EBM, including modes of teaching and the timing of delivering EBM content within the broader medical curriculum. Further research is required to determine the effects of timing, content and length of EBM courses and teaching methods.

How much evidence does it take? A cumulative meta‐analysis of outcomes of simulation‐based education

Abstract: Context Studies that investigate research questions that have already been resolved represent a waste of resources. However, the failure to collect sufficient evidence to resolve a given question results in ambiguity. Objectives The present study was conducted to reanalyse the results of a meta-analysis of simulation-based education (SBE) to determine: (i) whether researchers continue to replicate research studies after the answer to a research question has become known, and (ii) whether researchers perform enough replications to definitively answer important questions. Methods A systematic search of multiple databases to May 2011 was conducted to identify original research evaluating SBE for health professionals in comparison with no intervention or any active intervention, using skill outcomes. Data were extracted by reviewers working in duplicate. Data synthesis involved a cumulative meta-analysis to illuminate patterns of evidence by sequentially adding studies according to a variable of interest (e.g. publication year) and re-calculating the pooled effect size with each addition. Cumulative meta-analysis by publication year was applied to 592 comparative studies using several thresholds of ‘sufficiency’, including: statistical significance; stable effect size classification and magnitude (Hedges’ g ± 0.1), and precise estimates (confidence intervals of less than ± 0.2). Results Among studies that compared the outcomes of SBE with those of no intervention, evidence supporting a favourable effect of SBE on skills existed as early as 1973 (one publication) and further evidence confirmed a quantitatively large effect of SBE by 1997 (28 studies). Since then, a further 404 studies were published. Among studies comparing SBE with non-simulation instruction, the effect initially favoured non-simulation training, but the addition of a third study in 1997 brought the pooled effect to slightly favour simulation, and by 2004 (14 studies) this effect was statistically significant (p < 0.05) and the magnitude had stabilised (small effect). A further 37 studies were published after 2004. By contrast, evidence from studies evaluating repetition continued to show borderline statistical significance and wide confidence intervals in 2011. Conclusions Some replication is necessary to obtain stable estimates of effect and to explore different contexts, but the number of studies of SBE often exceeds the minimum number of replications required.

Palliative care education in U.S. medical schools.

Abstract: Context Medical educators in the USA perceive the teaching of palliative care competencies as important, medical students experience it as valuable and effective, and demographic and societal forces fuel its necessity. Although it is encouraged by the Association of American Medical Colleges, the only palliative care-related mandate in US medical schools is the Liaison Committee on Medical Education directive that end-of-life (EoL) care be included in medical school curricula, reinforcing the problematic conflation of EoL and palliative care. Findings A review of US medical school surveys about the teaching of palliative and EoL care reveals varied and uneven approaches, ranging from 2 hours in the classroom on EoL to weeks of palliative care training or hospice-based clinical rotations. Implications Palliative care competencies are too complex and universally important to be relegated to a minimum of classroom time, random clinical exposures, and the hidden curriculum. Recommendations Given the reality of overstrained medical school curricula, developmentally appropriate, basic palliative care competencies should be defined and integrated into each year of the medical school curriculum, taking care to circumvent the twin threats of curricular overload and educational abandonment.

Competency‐based medical education: origins, perspectives and potentialities

Abstract: This article is part of a series in Medical Education entitled ‘Dialogue’. Each publication in the series will be a transcription of an e-mail discussion about a current issue in the field held by two scholars who have approached the issue from different perspectives. For further details, see the editorial published in Med Educ 2012;46 (9):826–7. In this volume, Olle ten Cate, PhD (University Medical Centre Utrecht, the Netherlands) and Stephen Billett, PhD (Griffith University, Brisbane, Queensland, Australia) conduct an e-mail conversation on competency-based professional training in medicine. The discussion addressed its roots, significance and limitations, and extended to considerations of canonical knowledge and skill versus context-dependent ability, and legitimate peripheral participation through the development of a growing portfolio of entrustable professional activities.

Why are medical students 'checking out' of active learning in a new curriculum?

Abstract: Objectives The University of Virginia School of Medicine recently transformed its pre-clerkship medical education programme to emphasise student engagement and active learning in the classroom. As in other medical schools, many students are opting out of attending class and others are inattentive while in class. We sought to understand why, especially with a new student-centred curriculum, so many students were still opting to learn on their own outside of class or to disengage from educational activities while in class. Methods Focus groups were conducted with students from two classes who had participated in the new curriculum, which is designed to foster small-group and collaborative learning. The sessions were audio-recorded and then transcribed. The authors read through all of the transcripts and then reviewed them for themes. Quotes were analysed and organised by theme. Results Interview transcripts revealed candid responses to questions about learning and the learning environment. The semi-structured nature of the interviews enabled the interviewers to probe unanticipated issues (e.g. reasons for choosing to sit with friends although that diminishes learning and attention). A content analysis of these transcripts ultimately identified three major themes embracing multiple sub-themes: (i) learning studio physical space; (ii) interaction patterns among learners, and (iii) the quality of and engagement in learning in the space. Conclusions Students' reluctance to engage in class activities is not surprising if classroom exercises are passive and not consistently well designed or executed as active learning exercises that students perceive as enhancing their learning through collaboration. Students' comments also suggest that their reluctance to participate regularly in class may be because they have not yet achieved the developmental level compatible with adult and active learning, on which the curriculum is based. Challenges include helping students better understand the nature of deep learning and their own developmental progress as learners, and providing robust faculty development to ensure the consistent deployment of higher-order learning activities linked with higher-order assessments.

Multiple mini-interviews: same concept, different approaches.

Abstract: Objectives Increasing numbers of educational institutions in the medical field choose to replace their conventional admissions interviews with a multiple mini-interview (MMI) format because the latter has superior reliability values and reduces interviewer bias. As the MMI format can be adapted to the conditions of each institution, the question of under which circumstances an MMI is most expedient remains unresolved. This article systematically reviews the existing MMI literature to identify the aspects of MMI design that have impact on the reliability, validity and cost-efficiency of the format. Methods Three electronic databases (OVID, PubMed, Web of Science) were searched for any publications in which MMIs and related approaches were discussed. Sixty-six publications were included in the analysis. Results Forty studies reported reliability values. Generally, raising the number of stations has more impact on reliability than raising the number of raters per station. Other factors with positive influence include the exclusion of stations that are too easy, and the use of normative anchored rating scales or skills-based rater training. Data on criterion-related validities and analyses of dimensionality were found in 31 studies. Irrespective of design differences, the relationship between MMI results and academic measures is small to zero. The McMaster University MMI predicts in-programme and licensing examination performance. Construct validity analyses are mostly exploratory and their results are inconclusive. Seven publications gave information on required resources or provided suggestions on how to save costs. The most relevant cost factors that are additional to those of conventional interviews are the costs of station development and actor payments. Conclusions The MMI literature provides useful recommendations for reliable and cost-efficient MMI designs, but some important aspects have not yet been fully explored. More theory-driven research is needed concerning dimensionality and construct validity, the predictive validity of MMIs other than those of McMaster University, the comparison of station types, and a cost-efficient station development process.

Professionalism: A framework to guide medical education

Abstract: Context Despite considerable advances in the incorporation of professionalism into the formal curriculum, medical students and residents are too often presented with a mechanical, unreflective version of the topic that fails to convey deeper ethical and humanistic aspirations. Some misunderstandings of professionalism are exacerbated by commonly used assessment tools that focus only on superficially observable behaviour and not on moral values and attitudes. Methods Following a selective literature review, we engaged in philosophical ethical analysis to identify the key precepts associated with professionalism that could best guide the development of an appropriately reflective curriculum. Results The key precepts needed for a robust presentation of professionalism can be grouped under two headings: ‘Professionalism as a trust-generating promise’ (representing commitment to patients’ interests, more than a mere business, a social contract, a public and collective promise, and hard work), and ‘Professionalism as application of virtue to practice’ (based on virtue, deeper attitudes rather than mere behaviour, and requiring of practical wisdom). Conclusions These key precepts help students to avoid many common, unreflective misunderstandings of professionalism, and guide faculty staff and students jointly to address the deeper issues required for successful professional identity formation.

Toward reciprocity: host supervisor perspectives on international medical electives

Abstract: Context An increasing number of medical students are engaging in international medical electives, the majority of which involve travel from northern, higher-income countries to southern, lower-income countries. Existing research has identified benefits to students participating in these experiences. However, reports on the impacts on host communities are largely absent from the literature. Objectives The current study aims to identify host country perspectives on international medical electives. Methods Questionnaires were delivered to a convenience sample of supervisors hosting international elective students (n = 39) from a Canadian medical school. Responses represented 22 countries. Conventional content analysis of the qualitative data was used to identify themes in host supervisor perspectives on the impact of international medical electives. Results Host country supervisors identified that in addition to the benefits realised by the elective students, supervisors and their institutions also benefited from hosting Canadian students. Although some host supervisors denied the occurrence of any harm, others expressed concern that international elective students may negatively impact the local community in terms of resource use and patient care. Host country supervisors also identified potential harms to travelling students including health risks and emotional distress. Ideas for improving international electives were identified and were largely centred around increasing the bidirectional flow of students by establishing formal partnerships between institutions. Conclusions This research provides important insights into the impacts of international medical student electives from the perspective of host country supervisors. This research may be a starting point for further research and the establishment of meaningful partnerships that incorporate the self-identified needs of receiving institutions, especially those in lower-income settings.

'Even now it makes me angry': health care students' professionalism dilemma narratives

Abstract: Context: Medical students encounter situations during workplace learning in which they witness or participate in something unprofessional (so-called professionalism dilemmas), sometimes having a negative emotional impact on them. Less is known about other health care students’ experiences of professionalism dilemmas and the resulting emotional impact. Objectives: To examine dental, nursing, pharmacy and physiotherapy students’ narratives of professionalism dilemmas: the types of events they encounter (‘whats’) and the ways in which they narrate those events (‘hows’). Methods: A qualitative cross-sectional study. Sixty-nine health care students (29 dentistry, 13 nursing, 12 pharmacy, 15 physiotherapy) participated in group/individual narrative interviews. Data were analysed using framework analysis (examining the ‘whats’), linguistic inquiry and word count software (examining the ‘hows’ by dilemma type and student group) and narrative analysis (bringing together ‘whats’ and ‘hows’). Results: In total, 226 personal incident narratives (104 dental, 34 nursing, 39 pharmacy and 49 physiotherapy) were coded. Framework analysis identified nine themes, including ‘Theme 2: professionalism dilemmas’, comprising five sub-themes: ‘student abuse’, ‘patient safety and dignity breaches by health care professionals’, ‘patient safety and dignity breaches by students’, ‘whistleblowing and challenging’ and ‘consent’. Using Linguistic Inquiry and Word Count (liwc) software, significant differences in negative emotion talk were found across student groups and dilemma types (e.g. more anger talk when narrating patient safety and dignity breaches by health care professionals than similar breaches by students). The narrative analysis illustrates how events are constructed and the emotional implications of assigning blame (an ethical dimension) resulting in emotional residue. Conclusion: Professionalism dilemmas experienced by health care students, including issues concerning whistleblowing and challenging, have implications for interprofessional learning. By focusing on common professionalism issues at a conceptual level, health care students can share experiences through narratives. The role-playing of idealised actions (how students wish they had acted) can facilitate synergy between personal moral values and moral action enabling students to commit and re-commit to professionalism values together.

Exploring clinical reasoning in novices: a self-regulated learning microanalytic assessment approach

Abstract: Objectives The primary objectives of this study were to examine the regulatory processes of medical students as they completed a diagnostic reasoning task and to examine whether the strategic quality of these regulatory processes were related to short-term and longer-term medical education outcomes.

What is appropriate to post on social media? Ratings from students, faculty members and the public

Abstract: Objectives The purpose of this study was to ascertain what medical students, doctors and the public felt was unprofessional for medical students, as future doctors, to post on a social media site, Facebook®. The significance of this is that unprofessional content reflects poorly on a student, which in turn can significantly affect a patient's confidence in that student's clinical abilities. Methods An online survey was designed to investigate the perceptions of University of Michigan medical students, attending physicians and non-health care university-wide employees (that serves as a subset of the public) regarding mock medical students' Facebook® profile screenshots. For each screenshot, respondents used a 5-point Likert scale to rate ‘appropriateness’ and whether they would be ‘comfortable’ having students posting such content as their future doctors. Results Compared with medical students, faculty members and public groups rated images as significantly less appropriate (p < 0.001) and indicated that they would be less comfortable (p < 0.001) having posting students as future doctors. All three groups rated screenshots containing derogatory or private information about patients, followed by images suggesting marijuana use, as least appropriate. Images conveying intimate heterosexual couples were rated as most appropriate. Overall, the doctor group, females and older individuals were less permissive when compared with employee and student groups, males and younger individuals, respectively. Conclusions The most significant conclusion of our study is that faculty members, medical students and the ‘public’ have different thresholds of what is acceptable on a social networking site. Our findings will prove useful for students to consider the perspectives of patients and faculty members when considering what type of content to post on their social media sites. In this way, we hope that our findings provide insight for discussions, awareness and the development of guidelines related to online professionalism for medical students.

Excellence in clinical teaching: knowledge transformation and development required

Abstract: Context Clinical teachers in medicine face the daunting task of mastering the many domains of knowledge needed for practice and teaching. The breadth and complexity of this knowledge continue to increase, as does the difficulty of transforming the knowledge into concepts that are understandable to learners. Properly targeted faculty development has the potential to expedite the knowledge transformation process for clinical teachers. Methods Based on my own research in clinical teaching and faculty development, as well as the work of others, I describe the unique forms of clinical teacher knowledge, the transformation of that knowledge for teaching purposes and implications for faculty development. Results The following forms of knowledge for clinical teaching in medicine need to be mastered and transformed: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and learners, and (iv) knowledge integrated into teaching scripts. This knowledge is employed and conveyed through the parallel processes of clinical reasoning and clinical instructional reasoning. Faculty development can facilitate this knowledge transformation process by: (i) examining, deconstructing and practising new teaching scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching. Conclusions To become an excellent clinical teacher in medicine requires the transformation of multiple forms of knowledge for teaching purposes. These domains of knowledge allow clinical teachers to provide tailored instruction to learners at varying levels in the context of fast-paced and demanding clinical practice. Faculty development can facilitate this knowledge transformation process.

Expertise in medicine: using the expert performance approach to improve simulation training.

Abstract: Context We critically review how medical education can benefit from systematic use of the expert performance approach as a framework for measuring and enhancing clinical practice. We discuss how the expert performance approach can be used to better understand the mechanisms underpinning superior performance among health care providers and how the framework can be applied to create simulated learning environments that present increased opportunities to engage in deliberate practice. Expert Performance Approach The expert performance approach is a systematic, evidence-based framework for measuring and analysing superior performance. It has been applied in a variety of domains, but has so far been relatively neglected in medicine and health care. Here we outline the framework and demonstrate how it can be effectively applied to medical education. Deliberate Practice Deliberate practice is defined as a structured and reflective activity, which is designed to develop a critical aspect of performance. Deliberate practice provides an opportunity for error detection and correction, repetition, access to feedback and requires maximal effort, complete concentration and full attention. We provide guidance on how to structure simulated learning environments to encourage the accumulation of deliberate practice. Conclusions We highlight the role of simulation-based training in conjunction with deliberate practice activities such as reflection, rehearsal, trial-and-error learning and feedback in improving the quality of patient care. We argue that the development of expertise in health care is directly related to the systematic identification and improvement of quantifiable performance metrics. In order to optimise the training of expert health care providers, advances in simulation technology need to be coupled with effective instructional systems design, with the latter being strongly guided by empirical research from the learning and cognitive sciences.

Shame, guilt, and the medical learner: ignored connections and why we should care

Abstract: Context Shame and guilt are subjective emotional responses that occur in response to negative events such as the making of mistakes or an experience of mistreatment, and have been studied extensively in the field of psychology. Despite their potentially damaging effects and ubiquitous presence in everyday life, very little has been written about the impact of shame and guilt in medical education. Methods The authors reference the psychology literature to define shame and guilt and then focus on one area in medical education in which they manifest: the response of the learner and teacher to medical errors. Evidence is provided from the psychology literature to show associations between shame and negative coping mechanisms, decreased empathy and impaired self-forgiveness following a transgression. The authors link this evidence to existing findings in the medical literature that may be related to unrecognised shame and guilt, and propose novel ways of thinking about a learner's ability to cope, remain empathetic and forgive him or herself following an error. Results The authors combine the discussion of shame, guilt and learner error with findings from the medical education literature and outline three specific ways in which teachers might lead learners to a shame-free response to errors: by acknowledging the presence of shame and guilt in the learner; by avoiding humiliation, and by leveraging effective feedback. Conclusions The authors conclude with recommendations for research on shame and guilt and their influence on the experience of the medical learner. This critical research plus enhanced recognition of shame and guilt will allow teachers and institutions to further cultivate the engaged, empathetic and shame-resilient learners they strive to create.

Computer‐based teaching module design: principles derived from learning theories

Abstract: Context The computer-based teaching module (CBTM), which has recently gained prominence in medical education, is a teaching format in which a multimedia program serves as a single source for knowledge acquisition rather than playing an adjunctive role as it does in computer-assisted learning (CAL). Despite empirical validation in the past decade, there is limited research into the optimisation of CBTM design. This review aims to summarise research in classic and modern multimedia-specific learning theories applied to computer learning, and to collapse the findings into a set of design principles to guide the development of CBTMs. Methods Scopus was searched for: (i) studies of classic cognitivism, constructivism and behaviourism theories (search terms: ‘cognitive theory’ OR ‘constructivism theory’ OR ‘behaviourism theory’ AND ‘e-learning’ OR ‘web-based learning’) and their sub-theories applied to computer learning, and (ii) recent studies of modern learning theories applied to computer learning (search terms: ‘learning theory’ AND ‘e-learning’ OR ‘web-based learning’) for articles published between 1990 and 2012. The first search identified 29 studies, dominated in topic by the cognitive load, elaboration and scaffolding theories. The second search identified 139 studies, with diverse topics in connectivism, discovery and technical scaffolding. Based on their relative representation in the literature, the applications of these theories were collapsed into a list of CBTM design principles. Results Ten principles were identified and categorised into three levels of design: the global level (managing objectives, framing, minimising technical load); the rhetoric level (optimising modality, making modality explicit, scaffolding, elaboration, spaced repeating), and the detail level (managing text, managing devices). Conclusions This review examined the literature in the application of learning theories to CAL to develop a set of principles that guide CBTM design. Further research will enable educators to take advantage of this unique teaching format as it gains increasing importance in medical education.

Into the future: patient-centredness endures in longitudinal integrated clerkship graduates

Abstract: Objectives This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time. Methods The authors’ earlier work compared the 27 graduates in the first three cohorts of students undertaking the CIC with a comparison group of 45 traditionally trained HMS students; CIC graduates emerged from their clerkship year with a higher degree of patient-centredness and felt more prepared to deal with numerous domains of patient care. Between April and July 2011, at 4–6 years post-clerkship, the authors asked these original study cohorts to complete an electronic survey which included measures used in the original study. The authors also reviewed data from the National Residency Match Program to compare career paths in the two groups. Results The response rate was 62% (42/68). The immediate post-clerkship finding that CIC students held more patient-centred attitudes was sustained over time (p < 0.035). Reflecting retrospectively on their clerkship experiences, CIC graduates continued to report that their clerkship year had better prepared them in a wide variety of domains. Graduates of the CIC attained awards and published papers at the same rates as peers, and were more likely to engage in health advocacy work. Both groups chose a wide range of residency programmes. Among those expressing a preference, no CIC graduates said they would choose a traditional clerkship, but 6 (27%) of the traditionally trained graduates said they would choose a longitudinal integrated clerkship. Conclusions This paper indicates that benefits of longitudinal integrated clerkship training are sustained over time across multiple domains.

Medical education... meet Michel Foucault.

Abstract: Context There have been repeated calls for the greater use of conceptual frameworks and of theory in medical education. Although it is familiar to few medical educators, Michel Foucault's work is a helpful theoretical and methodological source. Methods This article explores what it means to use a ‘Foucauldian approach’, presents a sample of Foucault's historical-genealogical studies that are relevant to medical education, and introduces the work of four researchers currently undertaking Foucauldian-inspired medical education research. Results Although they are not without controversy, Foucauldian approaches are employed by an increasing number of scholars and are helpful in shedding light on what it is possible to think, say and be in medical education. Conclusions Our hope in sharing this Foucauldian work and perspective is that we might stimulate a dialogue that is forward-looking and optimistic about the possibilities for change in medical education.

Legitimate workplace roles and activities for early learners

Abstract: Objectives Given the calls for earlier student engagement in clinical experiences, educators are challenged to define roles for pre-clerkship students that enable legitimate participation in clinical practice. This study aimed to determine the student roles and activities, as well as the clinic characteristics, that allow early student engagement within a specific clinical experience. Methods The authors conducted semi-structured interviews in December 2011 and January 2012 with a purposive sample of medical student and faculty volunteers at student-run clinics (SRCs). They were asked to discuss and compare student roles in SRCs with those in the core curriculum. An inductive approach and iterative process were used to analyse the interview transcripts. Themes identified from initial open coding were organised using the sensitising concepts of workplace learning and communities of practice and subsequently applied to code all transcripts. Results A total of 22 medical students and four faculty advisors were interviewed. Thematic analysis revealed pre-clerkship student roles in direct patient care (patient triage, history and physical examinations, patient education, laboratory and immunisation procedures) and in clinic management (patient follow-up, staff management, quality improvement). Students took ownership of patients and occupied central roles in the function of the clinic, with faculty staff serving as peripheral resources. Clinic-related features supporting this degree of legitimate participation included defined scopes of practice, limited presenting illnesses, focused student training, and clear protocols and operations manuals. Conclusions Pre-clerkship students are capable of legitimately participating in patient care experiences to an extent not usually available to them. The SRC represents one example of how early clinical experiences in the core curriculum might be transformed through the provision of patient care activities of narrow scope.

Ensuring high-quality patient care: the role of accreditation, licensure, specialty certification and revalidation in medicine.

Abstract: Context The accreditation of medical school programmes and the licensing and revalidation (or recertification) of doctors are thought to be important for ensuring the quality of health care. Whereas regulation of the medical profession is mandated in most jurisdictions around the world, the processes by which doctors become licensed, and maintain their licences, are quite varied. With respect to educational programmes, there has been a recent push to expand accreditation activities. Here too, the quality standards on which medical schools are judged can vary from one region to another. Objectives Given the perceived importance placed by the public and other stakeholders on oversight in medicine, both at the medical school and individual practitioner levels, it is important to document and discuss the regulatory practices employed throughout the world. Methods This paper describes current issues in regulation, provides a brief summary of research in the field, and discusses the need for further investigations to better quantify relationships among regulatory activities and improved patient outcomes. Discussion Although there is some evidence to support the value of medical school accreditation, the direct impact of this quality assurance initiative on patient care is not yet known. For both licensure and revalidation, some investigations have linked specific processes to quality indicators; however, additional evaluations should be conducted across the medical education and practice continuum to better elucidate the relationships among regulatory activities and patient outcomes. More importantly, the value of accreditation, licensure and revalidation programmes around the world, including the effectiveness of specific protocols employed in these diverse systems, needs to be better quantified and disseminated.

Key-feature questions for assessment of clinical reasoning: a literature review

Abstract: Objectives Key-feature questions (KFQs) have been developed to assess clinical reasoning skills. The purpose of this paper is to review the published evidence on the reliability and validity of KFQs to assess clinical reasoning. Methods A literature review was conducted by searching MEDLINE (1946–2012) and EMBASE (1980–2012) via OVID and ERIC. The following search terms were used: key feature; question or test or tests or testing or tested or exam; assess or evaluation, and case-based or case-specific. Articles not in English were eliminated. Results The literature search resulted in 560 articles. Duplicates were eliminated, as were articles that were not relevant; nine articles that contained reliability or validity data remained. A review of the references and of citations of these articles resulted in an additional 12 articles to give a total of 21 for this review. Format, language and scoring of KFQ examinations have been studied and modified to maximise reliability. Internal consistency reliability has been reported as being between 0.49 and 0.95. Face and content validity have been shown to be moderate to high. Construct validity has been shown to be good using vector thinking processes and novice versus expert paradigms, and to discriminate between teaching methods. The very modest correlations between KFQ examinations and more general knowledge-based examinations point to differing roles for each. Importantly, the results of KFQ examinations have been shown to successfully predict future physician performance, including patient outcomes. Conclusions Although it is inaccurate to conclude that any testing format is universally reliable or valid, published research supports the use of examinations using KFQs to assess clinical reasoning. The review identifies areas of further study, including all categories of evidence. Investigation into how examinations using KFQs integrate with other methods in a system of assessment is needed.