Showing papers in "Medical Education in 2018"

Academic outcomes of flipped classroom learning: a meta-analysis.

Abstract: Context The flipped classroom (FC), reversing lecture and homework elements of a course, is popular in medical education. The FC uses technology-enhanced pre-class learning to transmit knowledge, incorporating in-class interaction to enhance higher cognitive learning. However, the FC model is expensive and research on its effectiveness remains inconclusive. The aim of this study was to compare the efficacy of the FC model over traditional lecture-based (LB) learning by meta-analysis. Methods We systematically searched MEDLINE, PubMed, ERIC, CINAHL, EMBASE, reference lists and Association for Medical Education in Europe (AMEE) conference books. Controlled trials comparing academic outcomes between the FC and LB approaches in higher education were considered eligible. The main findings were pooled using a random-effects model when appropriate. Results Forty-six studies (9026 participants) were included, comprising four randomised controlled trials (RCTs), 19 quasi-experimental studies and 23 cohort studies. Study populations were health science (n = 32) and non health science (n = 14) students. The risk of bias was high (36/37 articles). Meta-analyses revealed that the FC had significantly better outcomes than the LB method in examination scores (post-intervention and pre-post change) and course grades, but not in objective structured clinical examination scores. Subgroup analyses showed the advantage of the FC was not observed in RCTs, non-USA countries, nursing and other health science disciplines and earlier publication years (2013 and 2014). Cumulative analysis and meta-regression suggested a tendency for progressively better outcomes by year. Outcome assessments rarely focused on behaviour change. Conclusions The FC method is associated with greater academic achievement than the LB approach for higher-level learning outcomes, which has become more obvious in recent years. However, results should be interpreted with caution because of the high methodological diversity, statistical heterogeneity and risk of bias in the studies used. Future studies should have high methodological rigour, a standardised FC format and utilise assessment tools evaluating higher cognitive learning and behaviour change to further examine differences between FC and LB learning.

What do we know about coaching in medical education? A literature review.

Abstract: Context Coaching has been employed successfully in the competitive sports, professional music, and business and corporate worlds. It is now emerging as a training modality in medical education. Objectives This paper reviews the current evidence on coaching strategies for doctors and medical students. Methods An applied literature search was conducted in PubMed, MEDLINE and Web of Science. Predetermined definitions of coaching interventions and their evaluations were used to narrow 993 papers down to 21, which were included in the final review. The 21 papers were critiqued with reference to validated scoring metrics. Results There are many papers discussing the merits of coaching in the world of medicine, but few evaluations of coaching interventions. Existing coaching methodologies can be broadly summarised into three categories: coaching for doctor/student well-being and resilience; coaching for improved non-technical skills, and coaching for technical skills. Identification of suitable papers for inclusion is complicated by theoretical uncertainty regarding coaching: many papers use the term as a synonym for teaching or mentoring. The strongest evidence for coaching lies in the teaching of technical skills. Conclusions There is weak- to medium-strength evidence to support coaching as a method of improving doctor well-being and enhancing non-technical skills, although the evidence base is limited as a whole. This review identifies strong evidence to support coaching as a method to improve technical skills. There is great scope for further studies investigating the power of coaching in medical students and doctors.

Self‐regulated learning in the clinical context: a systematic review

Abstract: Objectives: Research has suggested beneficial effects of self-regulated learning (SRL) for medical students' and residents' workplace-based learning. Ideally, learners go through a cyclic process of setting learning goals, choosing learning strategies and assessing progress towards goals. A clear overview of medical students' and residents' successful key strategies, influential factors and effective interventions to stimulate SRL in the workplace is missing. This systematic review aims to provide an overview of and a theoretical base for effective SRL strategies of medical students and residents for their learning in the clinical context. Methods: This systematic review was conducted according to the guidelines of the Association for Medical Education in Europe. We systematically searched PubMed, EMBASE, Web of Science, PsycINFO, ERIC and the Cochrane Library from January 1992 to July 2016. Qualitative and quantitative studies were included. Two reviewers independently performed the review process and assessed the methodological quality of included studies. A total of 3341 publications were initially identified and 18 were included in the review. Results: We found diversity in the use of SRL strategies by medical students and residents, which is linked to individual (goal setting), contextual (time pressure, patient care and supervision) and social (supervisors and peers) factors. Three types of intervention were identified (coaching, learning plans and supportive tools). However, all interventions focused on goal setting and monitoring and none on supporting self-evaluation. Conclusions: Self-regulated learning in the clinical environment is a complex process that results from an interaction between person and context. Future research should focus on unravelling the process of SRL in the clinical context and specifically on how medical students and residents assess their progress towards goals.

Context matters when striving to promote active and lifelong learning in medical education.

Abstract: Where do we stand now? In the 30 years that have passed since The Edinburgh Declaration on Medical Education, we have made tremendous progress in research on fostering ‘self-directed and independent study’ as propagated in this declaration, of which one prime example is research carried out on problem-based learning. However, a large portion of medical education happens outside of classrooms, in authentic clinical contexts. Therefore, this article discusses recent developments in research regarding fostering active learning in clinical contexts. Self-regulated, lifelong learning in medical education Clinical contexts are much more complex and flexible than classrooms, and therefore require a modified approach when fostering active learning. Recent efforts have been increasingly focused on understanding the more complex subject of supporting active learning in clinical contexts. One way of doing this is by using theory regarding self-regulated learning (SRL), as well as situated learning, workplace affordances, self-determination theory and achievement goal theory. Combining these different perspectives provides a holistic view of active learning in clinical contexts. Entry to practice, vocational training and continuing professional development Research on SRL in clinical contexts has mostly focused on the undergraduate setting, showing that active learning in clinical contexts requires not only proficiency in metacognition and SRL, but also in reactive, opportunistic learning. These studies have also made us aware of the large influence one's social environment has on SRL, the importance of professional relationships for learners, and the role of identity development in learning in clinical contexts. Additionally, research regarding postgraduate lifelong learning also highlights the importance of learners interacting about learning in clinical contexts, as well as the difficulties that clinical contexts may pose for lifelong learning. However, stimulating self-regulated learning in undergraduate medical education may also make postgraduate lifelong learning easier for learners in clinical contexts.

Stakes in the eye of the beholder: an international study of learners' perceptions within programmatic assessment.

Abstract: Objectives Within programmatic assessment, the ambition is to simultaneously optimise the feedback and the decision-making function of assessment. In this approach, individual assessments are intended to be low stakes. In practice, however, learners often perceive assessments designed to be low stakes as high stakes. In this study, we explored how learners perceive assessment stakes within programmatic assessment and which factors influence these perceptions. Methods Twenty-six learners were interviewed from three different countries and five different programmes, ranging from undergraduate to postgraduate medical education. The interviews explored learners' experience with and perception of assessment stakes. An open and qualitative approach to data gathering and analyses inspired by the constructivist grounded theory approach was used to analyse the data and reveal underlying mechanisms influencing learners' perceptions. Results Learners' sense of control emerged from the analysis as key for understanding learners' perception of assessment stakes. Several design factors of the assessment programme provided or hindered learners' opportunities to exercise control over the assessment experience, mainly the opportunities to influence assessment outcomes, to collect evidence and to improve. Teacher-learner relationships that were characterised by learners' autonomy and in which learners feel safe were important for learners' believed ability to exercise control and to use assessment to support their learning. Conclusions Knowledge of the factors that influence the perception of assessment stakes can help design effective assessment programmes in which assessment supports learning. Learners' opportunities for agency, a supportive programme structure and the role of the teacher are particularly powerful mechanisms to stimulate the learning value of programmatic assessment.

Developing and rewarding teachers as educators and scholars: remarkable progress and daunting challenges.

Abstract: Context This article describes the scholarly work that has addressed the fifth recommendation of the 1988 World Conference on Medical Education: ‘Train teachers as educators, not content experts alone, and reward excellence in this field as fully as excellence in biomedical research or clinical practice’. Progress Over the past 30 years, scholars have defined the preparation needed for teaching and other educator roles, and created faculty development delivery systems to train teachers as educators. To reward the excellence of educators, scholars have expanded definitions of scholarship, defined educator roles and criteria for judging excellence, and developed educator portfolios to make achievements visible for peer review. Despite these efforts, the scholarship of discovery continues to be more highly prized and rewarded than the scholarship of teaching. These values are deeply embedded in university culture and policies. Challenges To remedy the structural inequalities between researchers and educators, a holistic approach to rewarding the broad range of educational roles and educational scholarship is needed. This requires strong advocacy to create changes in academic rewards and support policies, provide a clear career trajectory for educators using learning analytics, expand programmes for faculty development, support health professions education scholarship units and academies of medical educators, and create mechanisms to ensure high standards for all educators.

CPD of the future: a partnership between quality improvement and competency‐based education

Abstract: Context Many of those involved in continuing professional development (CPD) over the past 10 years have engaged in discussions about its goals and activities. Whereas in the past CPD was viewed as an education intervention directed towards the medical expert role, recent research highlights the need to expand the scope of CPD and to promote its more explicit role in improving patient care and health outcomes. Recent developments in quality improvement (QI) and competency-based medical education (CBME), guided by appropriate theories of learning and change, can shed light on how the field might best advance. This paper describes principles of QI and CBME and how they might contribute to CPD, explores theoretical perspectives that inform such an integration and suggests a future model of CPD. Discussion Continuing professional development seeks to improve patient outcomes by increasing physician knowledge and skills and changing behaviours, whereas QI takes the approach of system and process change. Combining the strengths of a CPD approach with strategies known to be effective from the field of QI has the potential to harmonise the contributions of each, and thereby to lead to better patient outcomes. Similarly, competency-based CPD is envisioned to place health needs and patient outcomes at the centre of a CPD system that will be guided by a set of competencies to enhance the quality of practice and the safety of the health system. Conclusions We propose that the future CPD system should adhere to the following principles: it should be grounded in the everyday workplace, integrated into the health care system, oriented to patient outcomes, guided by multiple sources of performance and outcome data, and team-based; it should employ the principles and strategies of QI, and should be taken on as a collective responsibility by physicians, CPD provider organisations, regulators and the health system.

Competency‐based medical education: the discourse of infallibility

Abstract: Background Over the last two decades, competency-based frameworks have been internationally adopted as the primary educational approach in medicine. Yet competency-based medical education (CBME) remains contested in the academic literature. We look broadly at the nature of this debate to explore how it may shape scholars’ understanding of CBME, and its implications for medical education research and practice. In doing so, we deconstruct unarticulated discourses and assumptions embedded in the CBME literature. Methods We assembled an archive of literature focused on CBME. The archive dates from 1996, the publication year of the first CanMEDS Physician Competency Framework. We then conducted a Foucauldian critical discourse analysis (CDA) to delineate the dominant discourses underpinning the literature. CDA examines the intersections of language, social practices, knowledge and power relations to highlight how entrenched ways of thinking influence what can or cannot be said about a topic. Findings Detractors of CBME have advanced an array of conceptual critiques. Proponents have often responded with a recurring discursive strategy that minimises these critiques and deflects attention from the underlying concept of the competency-based approach. As part of this process, conceptual concerns are reframed as two practical problems: implementation and interpretation. Yet the assertion that these are the construct's primary concerns was often unsupported by empirical evidence. These practices contribute to a discourse of infallibility of CBME. Discussion In uncovering the discourse of infallibility, we explore how it can silence critical voices and hinder a rigorous examination of the competency-based approach. These discursive practices strengthen CBME by constructing it as infallible in the literature. We propose re-approaching the dialogue surrounding CBME as a starting point for empirical investigation, driven by the aim to broaden scholars’ understanding of its design, development and implementation in medical education.

The superiority of three-dimensional physical models to two-dimensional computer presentations in anatomy learning.

Abstract: BACKGROUND Although several studies (Anat Sci Educ, 8 [6], 525, 2015) have shown that computer-based anatomy programs (three-dimensional visualisation technology [3DVT]) are inferior to ordinary physical models (PMs), the mechanism is not clear. In this study, we explored three mechanisms: haptic feedback, transfer-appropriate processing and stereoscopic vision. METHODS The test of these hypotheses required nine groups of 20 students: two from a previous study (Anat Sci Educ, 6 [4], 211, 2013) and seven new groups. (i) To explore haptic feedback from physical models, participants in one group were allowed to touch the model during learning; in the other group, they could not; (ii) to test 'transfer-appropriate processing' (TAP), learning ( PM or 3DVT) was crossed with testing (cadaver or two-dimensional display of cadaver); (iii) finally, to examine the role of stereo vision, we tested groups who had the non-dominant eye covered during learning and testing, during learning, or not at all, on both PM and 3DVT. The test was a 15-item short-answer test requiring naming structures on a cadaver pelvis. A list of names was provided. RESULTS The test of haptic feedback showed a large advantage of the PM over 3DVT regardless of whether or not participants had haptic feedback: 67% correct for the PM with haptic feedback, 69% for PM without haptic feedback, versus 41% for 3DVT (p < 0.0001). In the study of TAP, the PM had an average score of 74% versus 43% for 3DVT (p < 0.0001) regardless of two-dimensional versus three-dimensional test outcome. The third study showed that the large advantage of the PM over 3DVT (28%) with binocular vision nearly disappeared (5%) when the non-dominant eye was covered for both learning and testing. CONCLUSIONS A physical model is superior to a computer projection, primarily as a consequence of stereoscopic vision with the PM. The results have implications for the use of digital technology in spatial learning.

Considering the interdependence of clinical performance: implications for assessment and entrustment.

Abstract: INTRODUCTION Our ability to assess independent trainee performance is a key element of competency-based medical education (CBME). In workplace-based clinical settings, however, the performance of a trainee can be deeply entangled with others on the team. This presents a fundamental challenge, given the need to assess and entrust trainees based on the evolution of their independent clinical performance. The purpose of this study, therefore, was to understand what faculty members and senior postgraduate trainees believe constitutes independent performance in a variety of clinical specialty contexts. METHODS Following constructivist grounded theory, and using both purposive and theoretical sampling, we conducted individual interviews with 11 clinical teaching faculty members and 10 senior trainees (postgraduate year 4/5) across 12 postgraduate specialties. Constant comparative inductive analysis was conducted. Return of findings was also carried out using one-to-one sessions with key informants and public presentations. RESULTS Although some independent performances were described, participants spoke mostly about the exceptions to and disclaimers about these, elaborating their sense of the interdependence of trainee performances. Our analysis of these interdependence patterns identified multiple configurations of coupling, with the dominant being coupling of trainee and supervisor performance. We consider how the concept of coupling could advance workplace-based assessment efforts by supporting models that account for the collective dimensions of clinical performance. CONCLUSION These findings call into question the assumption of independent performance, and offer an important step toward measuring coupled performance. An understanding of coupling can help both to better distinguish independent and interdependent performances, and to consider revising workplace-based assessment approaches for CBME.

Availability of cookies during an academic course session affects evaluation of teaching.

Abstract: Objectives Results from end-of-course student evaluations of teaching (SETs) are taken seriously by faculties and form part of a decision base for the recruitment of academic staff, the distribution of funds and changes to curricula. However, there is some doubt as to whether these evaluation instruments accurately measure the quality of course content, teaching and knowledge transfer. We investigated whether the provision of chocolate cookies as a content-unrelated intervention influences SET results. Methods We performed a randomised controlled trial in the setting of a curricular emergency medicine course. Participants were 118 third-year medical students. Participants were randomly allocated into 20 groups, 10 of which had free access to 500 g of chocolate cookies during an emergency medicine course session (cookie group) and 10 of which did not (control group). All groups were taught by the same teachers. Educational content and course material were the same for both groups. After the course, all students were asked to complete a 38-question evaluation form. Results A total of 112 students completed the evaluation form. The cookie group evaluated teachers significantly better than the control group (113.4 ± 4.9 versus 109.2 ± 7.3; p = 0.001, effect size 0.68). Course material was considered better (10.1 ± 2.3 versus 8.4 ± 2.8; p = 0.001, effect size 0.66) and summation scores evaluating the course overall were significantly higher (224.5 ± 12.5 versus 217.2 ± 16.1; p = 0.008, effect size 0.51) in the cookie group. Conclusions The provision of chocolate cookies had a significant effect on course evaluation. These findings question the validity of SETs and their use in making widespread decisions within a faculty.

Making the leap to medical education: a qualitative study of medical educators' experiences.

Abstract: Background Medical educators often have prior and primary experience in other academic and clinical disciplines. Individuals seeking successful careers in the education of medical students and doctors must, at some point in their development, make a conscious transition into a new identity as a medical educator. This is a necessary move if individuals are to commit to acquiring and maintaining specialist expertise in medical education. Some achieve this transition successfully, while others struggle and may even lose interest and abandon the endeavour. We explored senior educators’ experiences of achieving the transition into medical education and their views on what helps and hinders the process. Methods In 2015 we conducted three focus groups with 15 senior medical educators. All focus groups were audio recorded and transcribed verbatim. We applied transition theory to guide our deductive analysis, using Schlossberg’s Four S (4S) framework to code and report the participants’ self-reported perceptions of those factors relating to Self, Situation, Support and Strategy that had assisted them to make a successful transition to a fully acknowledged medical educator identity. Through inductive analysis, we then identified 17 explanatory sub-themes that were common to all three focus groups. Results Background and circumstances, individual motivation, a sense of control, organisational support, and effective networking and information seeking behaviour were factors identified as contributing to successful transition into, and maintenance of, a strong self-identity as a medical educator. Conclusions The experiences of established medical educators, and in particular an exploration of the factors that have facilitated their transition to an acknowledged self-identity as a medical educator could assist in supporting new educators to cope with the changes involved in developing as a medical educator.

Very-short-answer questions: reliability, discrimination and acceptability

Abstract: CONTEXT: Single-best-answer questions (SBAQs) have been widely used to test knowledge because they are easy to mark and demonstrate high reliability. However, SBAQs have been criticised for being subject to cueing. OBJECTIVES: We used a novel assessment tool that facilitates efficient marking of open-ended very-short-answer questions (VSAQs). We compared VSAQs with SBAQs with regard to reliability, discrimination and student performance, and evaluated the acceptability of VSAQs. METHODS: Medical students were randomised to sit a 60-question assessment administered in either VSAQ and then SBAQ format (Group 1, n = 155) or the reverse (Group 2, n = 144). The VSAQs were delivered on a tablet; responses were computer-marked and subsequently reviewed by two examiners. The standard error of measurement (SEM) across the ability spectrum was estimated using item response theory. RESULTS: The review of machine-marked questions took an average of 1 minute, 36 seconds per question for all students. The VSAQs had high reliability (alpha: 0.91), a significantly lower SEM than the SBAQs (p < 0.001) and higher mean item-total point biserial correlations (p < 0.001). The VSAQ scores were significantly lower than the SBAQ scores (p < 0.001). The difference in scores between VSAQs and SBAQs was attenuated in Group 2. Although 80.4% of students found the VSAQs more difficult, 69.2% found them more authentic. CONCLUSIONS: The VSAQ format demonstrated high reliability and discrimination and items were perceived as more authentic. The SBAQ format was associated with significant cueing. The present results suggest the VSAQ format has a higher degree of validity.

Supervised workplace learning in postgraduate training: a realist synthesis

Abstract: This paper presents a realist synthesis of the literature that began with the objective of developing a theory of workplace learning specific to postgraduate medical education (PME). As the review progressed, we focused on informal learning between trainee and senior doctor or supervisor, asking what mechanisms occur between trainee and senior doctor that lead to the outcomes of PME, and what contexts shape the operation of these mechanisms and the outcomes they produce?

Back from basics: integration of science and practice in medical education.

Abstract: Context In 1988, the Edinburgh Declaration challenged medical teachers, curriculum designers and leaders to make an organised effort to change medical education for the better. Among a series of recommendations was a call to integrate training in science and clinical practice across a breadth of clinical contexts. The aim was to create physicians who could serve the needs of all people and provide care in a multitude of contexts. In the years since, in the numerous efforts towards integration, new models of curricula have been proposed and implemented with varying levels of success. Scope of Review In this paper, we examine the evolution of curricular integration since the Edinburgh Declaration, and discuss theoretical advances and practical solutions. In doing so, we draw on recent consensus reports on the state of medical education, emblematic initiatives reported in the literature, and developments in education theory pertinent to the role of integrated curricula. Conclusions Interest in integration persists despite 30 years of efforts to respond to the Edinburgh Declaration. We argue, however, that a critical shift has taken place with respect to the conception of integration, whereby empirical models support a view of integration as pertaining to both cognitive activity and curricular structure. In addition, we describe a broader definition of ‘basic science’ relevant to clinical practice that encompasses social and behavioural sciences, as well as knowledge derived from biomedical science.

Duration and setting of rural immersion during the medical degree relates to rural work outcomes.

Abstract: Context: Providing year-long rural immersion as part of the medical degree is commonly used to increase the number of doctors with an interest in rural practice. However, the optimal duration and setting of immersion has not been fully established. This paper explores associations between various durations and settings of rural immersion during the medical degree and whether doctors work in rural areas after graduation. Methods: Eligible participants were medical graduates of Monash University between 2008 and 2016 in postgraduate years 1-9, whose characteristics, rural immersion information and work location had been prospectively collected. Separate multiple logistic regression and multinomial logit regression models tested associations between the duration and setting of any rural immersion they did during the medical degree and (i) working in a rural area and (ii) working in large or smaller rural towns, in 2017. Results: The adjusted odds of working in a rural area were significantly increased if students were immersed for one full year (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.15–2.79), for between 1 and 2 years (OR, 2.26; 95% CI, 1.54–3.32) and for 2 or more years (OR, 4.43; 95% CI, 3.03–6.47) relative to no rural immersion. The strongest association was for immersion in a mix of both regional hospitals and rural general practice (OR, 3.26; 95% CI, 2.31–4.61), followed by immersion in regional hospitals only (OR, 1.94; 95% CI, 1.39–2.70) and rural general practice only (OR, 1.91; 95% CI, 1.06–3.45). More than 1 year's immersion in a mix of regional hospitals and rural general practices was associated with working in smaller regional or rural towns (<50 000 population) (relative risk ratios [RRR] 2.97; 95% CI, 1.82–4.83). Conclusion: These findings inform medical schools about effective rural immersion programmes. Longer rural immersion and immersion in both regional hospitals and rural general practices are likely to increase rural work and rural distribution of early career doctors.

Implementation and impact of indigenous health curricula: a systematic review.

Abstract: Context The effectiveness of cultural competency education in improving health practitioner proficiency and addressing health inequities for minoritised patient groups is uncertain. Identification of institutional factors that shape or constrain development of indigenous health curricula may provide insights into the impact of these factors on the broader cultural competency curricula. Methods We undertook a systematic review using actor-network theory to inform our interpretive synthesis of studies that reported indigenous health curricula evaluated within medical, nursing and allied health education. We searched the MEDLINE, OVID Nursing, Educational Resources Information Center (ERIC), PsycINFO, EMBASE, Web of Science and PubMed databases to December 2017 using exploded MeSH terms 'indigenous' and 'medical education' and 'educational professional' and 'health professional education'. We included studies involving undergraduate or postgraduate medical, nursing or allied health students or practitioners. Studies were eligible if they documented indigenous health learning outcomes, pedagogical practices and student evaluations. Results Twenty-three studies were eligible for the review. In an interpretive synthesis informed by actor-network theory, three themes emerged from the data: indigenous health as an emerging curriculum (drivers of institutional change, increasing indigenous capacity and leadership, and addressing deficit discourse); institutional resource allocation to indigenous health curricula (placement within the core curriculum, time allocation, and resources constraining pedagogy), and impact of the curriculum on learners (acceptability of the curriculum, learner knowledge, and learner behaviour). Conclusions Systemic barriers acting on and within educational networks have limited the developmental capacity of indigenous health curricula, supported and sustained hidden curricula, and led to insufficient institutional investment to support a comprehensive curriculum. Future research in health professional education should explore these political and network intermediaries acting on cultural competence curricula and how they can be overcome to achieve cultural competency learning outcomes.

Discrimination, harassment and non-reporting in UK medical education

Abstract: CONTEXT Discrimination and harassment create a hostile environment with deleterious effects on student well-being and education. In this study, we aimed to: (i) measure prevalences and types of discrimination and harassment in one UK medical school, and (ii) understand how and why students report them. METHODS The study used a mixed-methods design. A medical school population survey of 1318 students was carried out in March 2014. Students were asked whether they had experienced, witnessed or reported discrimination or harassment and were given space for free-text comments. Two focus group sessions were conducted to elicit information on types of harassment and the factors that influenced reporting. Proportions were analysed using the Wilson score method and associations tested using chi-squared and regression analyses. Qualitative data were subjected to framework analysis. Degrees of convergence between data were analysed. RESULTS A total of 259 (19.7%) students responded to the survey. Most participants had experienced (63.3%, 95% confidence interval [CI]: 57.3-69.0) or witnessed (56.4%, 95% CI: 50.3-62.3) at least one type of discrimination or harassment. Stereotyping was the form most commonly witnessed (43.2%, 95% CI: 37.4-49.3). In the qualitative data, reports of inappropriate joking and invasion of personal space were common. Black and minority ethnic students had witnessed and religious students had experienced a greater lack of provision (χ2 = 4.73, p = 0.03 and χ2 = 4.38, p = 0.04, respectively). Non-heterosexual students had experienced greater joking (χ2 = 3.99, p = 0.04). Students with disabilities had experienced more stereotyping (χ2 = 13.5, p < 0.01). Female students and students in clinical years had 2.6 (95% CI: 1.3-5.3) and 3.6 (95% CI: 1.9-7.0) greater odds, respectively, of experiencing or witnessing any type of discrimination or harassment. Seven of 140 survey respondents had reported incidents (5.0%, 95% CI: 2.4-10.0). Reporting was perceived as ineffective and as potentially victimising of the reporter. CONCLUSIONS Harassment and discrimination are prevalent in this sample and associated with gender, ethnicity, sexuality, disability and year group. Reporting is rare and perceived as ineffective. These findings have informed local developments, future strategies and the development of a national prevention policy.

Lessons learned from 15 years of non‐grades‐based selection for medical school

Abstract: textContext: Thirty years ago, it was suggested in the Edinburgh Declaration that medical school applicants should be selected not only on academic, but also on non-academic, attributes. The main rationale behind extending medical school selection procedures with the evaluation of (non-academic) personal qualities is that this will lead to the selection of students who will perform better as a doctor than those who are selected on the basis of academic measures only. A second rationale is the expectation that this will lead to a representative health workforce as a result of reduced adverse impact. The aims of this paper are (i) to describe what can be learned about the use of selection criteria other than grades from over 15 years of Dutch experience and (ii) to summarise current knowledge on the issue of adverse impact in relation to non-grades-based selection. Methods: A narrative review was undertaken of the (published) evidence that has resulted from non-grades-based school-specific selection procedures in the Netherlands and from recent explorations of the effect of the use of non-grades-based selection criteria on student diversity. Results: The Dutch evidence is grouped into five key themes: the effect of participation in voluntary selection procedures, the assessment of pre-university extracurricular activities, the use of work samples, Dutch experiences with situational judgement tests and the effects of changing circumstances. This is followed by several lessons learned for medical schools that aim to increase their student diversity. Conclusion: Over the last 30 years, important steps towards reliable and valid methods for measuring non-academic abilities have been taken. The current paper describes several lessons that can be learned from the steps taken in the Dutch context. The importance of sharing evidence gathered around the globe and building on this evidence to reach our goal of predicting who will be a good doctor is acknowledged.

Implementing economic evaluation in simulation-based medical education: challenges and opportunities.

Abstract: Context Simulation-based medical education (SBME) is now ubiquitous at all levels of medical training. Given the substantial resources needed for SBME, economic evaluation of simulation-based programmes or curricula is required to demonstrate whether improvement in trainee performance (knowledge, skills and attitudes) and health outcomes justifies the cost of investment. Current literature evaluating SBME fails to provide consistent and interpretable information on the relative costs and benefits of alternatives. Content Economic evaluation is widely applied in health care, but is relatively scarce in medical education. Therefore, in this paper, using a focus on SBME, we define economic evaluation, describe the key components, and discuss the challenges associated with conducting an economic evaluation of medical education interventions. As a way forward to the rigorous and state of the art application of economic evaluation in medical education, we outline the steps to gather the necessary information to conduct an economic evaluation of simulation-based education programmes and curricula, and describe the main approaches to conducting an economic evaluation. Conclusion A properly conducted economic evaluation can help stakeholders (i.e., programme directors, policy makers and curriculum designers) to determine the optimal use of resources in selecting the modality or method of assessment in simulation. It also helps inform broader decision making about allocation of scarce resources within an educational programme, as well as between education and clinical care. Economic evaluation in medical education research is still in its infancy, and there is significant potential for state-of-the-art application of these methods in this area.

Matching the production of doctors with national needs

Abstract: Context Matching the supply of health workers to need is necessary if a health system is to be sustainable, affordable and fit for purpose. On the 30th anniversary of the 1988 Edinburgh Declaration of the World Federation for Medical Education, levels of compliance with the 10th recommendation, ‘Ensure admission policies that match the numbers of students trained with national needs for doctors’, warrant review. There are two domains to such a review, concerning, respectively, how well these health needs are known, and whether workforce supply is well matched. Methods This is a literature review-based analysis of extant health system planning, which underpins current understanding of national health needs and of the consequent alignment of student selection processes. Results The core finding is that national need for doctors, and any other health workers, is not confidently known for any jurisdiction. Consequently, validation of student selection processes is impossible against this endpoint and data to validate these processes against the alternative endpoint of a positive impact on health outcomes do not exist. Data do exist to suggest some student selection processes result in desirable career and career location uptakes.

A critical narrative review of transfer of basic science knowledge in health professions education

Abstract: Context 'Transfer' is the application of a previously learned concept to solve a new problem in another context. Transfer is essential for basic science education because, to be valuable, basic science knowledge must be transferred to clinical problem solving. Therefore, better understanding of interventions that enhance the transfer of basic science knowledge to clinical reasoning is essential. This review systematically identifies interventions described in the health professions education (HPE) literature that document the transfer of basic science knowledge to clinical reasoning, and considers teaching and assessment strategies. Methods A systematic search of the literature was conducted. Articles related to basic science teaching at the undergraduate level in HPE were analysed using a 'transfer out'/'transfer in' conceptual framework. 'Transfer out' refers to the application of knowledge developed in one learning situation to the solving of a new problem. 'Transfer in' refers to the use of previously acquired knowledge to learn from new problems or learning situations. Results Of 9803 articles initially identified, 627 studies were retrieved for full text evaluation; 15 were included in the literature review. A total of 93% explored 'transfer out' to clinical reasoning and 7% (one article) explored 'transfer in'. Measures of 'transfer out' fostered by basic science knowledge included diagnostic accuracy over time and in new clinical cases. Basic science knowledge supported learning - 'transfer in' - of new related content and ultimately the 'transfer out' to diagnostic reasoning. Successful teaching strategies included the making of connections between basic and clinical sciences, the use of commonsense analogies, and the study of multiple clinical problems in multiple contexts. Performance on recall tests did not reflect the transfer of basic science knowledge to clinical reasoning. Conclusions Transfer of basic science knowledge to clinical reasoning is an essential component of HPE that requires further development for implementation and scholarship.

What really matters for successful research environments? A realist synthesis.

Abstract: Context: Research environments, or cultures, are thought to be the most influential predictors of research productivity Although several narrative and systematic reviews have begun to identify the characteristics of research‐favourable environments, these reviews have ignored the contextual complexities and multiplicity of environmental characteristics / Objectives: The current synthesis adopts a realist approach to explore what interventions work for whom and under what circumstances / Methods: We conducted a realist synthesis of the international literature in medical education, education and medicine from 1992 to 2016, following five stages: (i) clarifying the scope; (ii) searching for evidence; (iii) assessing quality; (iv) extracting data, and (v) synthesising data / Results: We identified numerous interventions relating to research strategy, people, income, infrastructure and facilities (IIF), and collaboration These interventions resulted in positive or negative outcomes depending on the context and mechanisms fired We identified diverse contexts at the individual and institutional levels, but found that disciplinary contexts were less influential There were a multiplicity of positive and negative mechanisms, along with three cross‐cutting mechanisms that regularly intersected: time; identity, and relationships Outcomes varied widely and included both positive and negative outcomes across subjective (eg researcher identity) and objective (eg research quantity and quality) domains / Conclusions: The interplay among mechanisms and contexts is central to understanding the outcomes of specific interventions, bringing novel insights to the literature Researchers, research leaders and research organisations should prioritise the protection of time for research, enculturate researcher identities, and develop collaborative relationships to better foster successful research environments Future research should further explore the interplay among time, identity and relationships

The impact of accreditation on medical schools' processes.

Abstract: This study was carried out to determine the impact of accreditation on medical schools’ processes and to examine whether processes developed as a result of accreditation align with those associated with best practices of continuous quality improvement. In addition, at each school, the predominant organizational culture was assessed as well as the perceived extent of implementation of continuing quality improvement. Sixteen (16) of the 17 medical schools in Canada were invited to participate; one (1) medical school was excluded, as the timing of the study would have significantly interfered with the regular accreditation activities taking place at that school. Thirteen (13) medical schools agreed to contribute to the study. Mixed methods were used. Individual and focus group interviews were held with leaders of the undergraduate medical education program at each school. In addition, all faculty members with either a leadership role or a teaching role within their undergraduate medical education program were invited to complete an electronic survey about the culture of their organization and the implementation of continuing quality improvement. Results showed that accreditation impacts several processes of medical schools, namely their governance structure, their data collection and analysis systems, their monitoring and documentation procedures, and the creation and revision of policies. It also encourages continuing quality improvement exercises and faculty engagement in the affairs of the medical education program. In some cases, it triggers a complete overhaul of the curriculum and of the academic accountability scheme. Most medical education programs in Canada have an Empirical culture, one that favors stability and conservatism. A Clan culture dominated at two medical education programs and was strong in two additional programs; this culture emphasizes organizational relationships, loyalty and commitment. Programs with a Clan culture tended to demonstrate a higher degree of implementation of quality improvement. Several of the processes developed or strengthened in response to accreditation align with best practices of continuing quality improvement. Programs with a Clan culture might better perceive accreditation-related processes as an integral component of their continuous quality improvement activities.

When I say … hermeneutic phenomenology.

Abstract: Among his duties, Hermes was responsible for delivering messages among the Greek gods and to the mortal world, and for interpreting those messages and conveying their underlying meaning. Hermeneutic phenomenology, like the messenger god with whom it shares its lexical root, is a qualitative research methodology that goes beyond describing a phenomenon to exploring and conveying its meaning in the context of everyday life. Sometimes referred to as interpretive phenomenology, hermeneutic phenomenology seeks to uncover the meaning and central structures, or essences, of a participant’s lived experience with a phenomenon and the contextual forces that shape it. As such, it can help researchers more fully understand complex, environmentally influenced phenomena, ranging from learner mistreatment and burnout to learners’ experiences on a clerkship or interprofessional team.

The influence of clerkship on students’ stigma towards mental illness: a meta‐analysis

Abstract: CONTEXT In university programmes preparing students to work with patients with mental illness, clerkship is proposed as a component that may contribute to the battle against stigma, through bringing students into contact with the patients' reality. Yet, the precise contribution of clerkship remains unclear, perhaps because of the variety of university programmes, clerkship characteristics or types of stigma explored. This is the first systematic meta-analysis of available evidence determining the precise effect size of the influence of clerkship on stigma and the potential moderators. METHODS We carried out a systematic literature review in Eric, PsycINFO, Pubmed, Scopus, UMI and Proquest dissertations, aiming to identify all the studies exploring health care students' stigma of mental illness (measured as overall stigma or as attitudes, affect and behavioural intentions) before and after a clerkship from 2000 to 2017. Twenty-two studies were included in the meta-analysis, providing data from 22 independent samples. The total sample consisted of 3161 students. The effects of programme (medicine, nursing, occupational therapy, and their combination), study design (paired-unpaired samples), publication year, sex, age and clerkship context, and inclusion of theoretical training and duration, were examined as potential moderators. RESULTS Our analyses yielded a highly significant medium effect size for overall stigma (Hedge's g = 0.35; p < 0.001; 95% confidence interval [CI], 0.20, 0.42), attitudes (Hedge's g = 0.308; p = 0.003; 95% CI, 0.10, 0.51) and behavioural intentions (Hedge's g = 0.247; p < 0.001; 95% CI, 0.17, 0.33), indicating a considerable change, whereas there was no significant change in the students' affect. Moderator analyses provided evidence for the distinct nature of each stigma outcome, as they were influenced by different clerkship and student characteristics such as clerkship context, theoretical training, age and sex. CONCLUSIONS The robust effect of clerkship on students' stigma of mental illness established by the present meta-analysis highlights its role as a crucial curriculum component for experiential learning and as a necessary agent for the battle against stigma.

‘Oh my God, I can't handle this!’: trainees’ emotional responses to complex situations

Abstract: Context Dealing with emotions is critical for medical trainees’ professional development. Taking a sociocultural and narrative approach to understanding emotions, we studied complex clinical situations as a specific context in which emotions are evoked and influenced by the social environment. We sought to understand how medical trainees respond to emotions that arise in those situations. Methods In an international constructivist grounded theory study, 29 trainees drew two rich pictures of complex clinical situations, one exciting and one frustrating. Rich pictures are visual representations that capture participants’ perceptions about the people, situations and factors that create clinical complexity. These pictures were used to guide semi-structured, individual interviews. We analysed visual materials and interviews in an integrated way, starting with looking at the drawings, doing a ‘gallery walk’, and using the interviews to inform the aesthetic analysis. Results Participants’ drawings depicted a range of personal emotions in response to complexity, and disclosed unsettling feelings and behaviours that might be considered unprofessional. When trainees felt confident, they were actively participating, engaged in creative problem-solving strategies, and emphasised their personal involvement. When trainees felt the situation was beyond their control, they described how they were running away from the situation, hiding themselves behind others or distancing themselves from patients or families. Conclusions A sense of control seems to be a key factor influencing trainees’ emotional and behavioural responses to complexity. This is problematic, as complex situations are by their nature emergent and dynamic, which limits possibilities for control. Following a social performative approach to emotions, we should help students understand that feeling out of control is an inherent property of participating in complex clinical situations, and, by extension, that it is not something they will ‘grow out of’ with expertise.

Coordinating medical education and health care systems: the power of the social accountability approach.

Abstract: Context As the purpose of medical education is to produce graduates able to most effectively address people's health concerns, there is general agreement that coordination with the health care system is essential. For too long, coordination has been dealt with in a subjective manner with only few landmarks to ensure objective and measurable achievements. Over the last 30 years, since the Edinburgh Declaration on medical education, progress has been made, namely with the concept of social accountability. Methods The social accountability approach provides a way to plan, deliver and assess medical education with the explicit aim to contribute to effective, equitable and sustainable health system development. It is based on a system-wide scope exploring issues from identification of people's and society's health needs to verification of the effects of medical education in meeting those needs. A wide international consultation among medical education leaders led to the adoption of the Global Consensus on Social Accountability of Medical Schools. Experiences Benchmarks of social accountability are in the process of being conceived and tested, enabling medical schools to steer medical education in a more purposeful way in relation to determinants of health. A sample of schools using the social accountability approach claims to have had a positive influence on health care system performance and people's health status. Conclusion Improved coordination of medical education and other key stakeholders in the health system is an important challenge for medical schools as well as for countries confronted with an urgent need for optimal use of their health workforce. There is growing interest worldwide in defining policies and strategies and supporting experiences in this regard.

Rationales for expanding minority physician representation in the workforce: a scoping review.

Abstract: Objectives The purpose of this study was to conduct a scoping review of the literature and to categorically map a 15-year trajectory of US undergraduate medical education rationales for and approaches to expanding under-represented minority (URM) physician representation in the medical workforce. Further aims were to comparatively examine related justifications and to consider international implications. Methods From 1 June to 31 July 2015, the authors searched the Cochrane Library, ERIC, PsycINFO, PubMed, Scopus, Web of Science and Google Scholar for articles published between 2000 and 2015 reporting rationales for and approaches to increasing the numbers of members of URMs in undergraduate medical school. Results A total of 137 articles were included in the scoping review. Of these, 114 (83%) mentioned workforce diversity and 73 (53%) mentioned concordance. The patient-physician relationship (n = 52, 38%) and service commitment (n = 52, 38%) were the most commonly cited rationales. The most frequently mentioned approaches to increasing minority representation were pipeline programmes (n = 59, 43%), changes in affirmative action laws (n = 32, 23%) and changes in admission policies (n = 29, 21%). Conclusions This scoping review of the 2000-2015 literature on strategies for and approaches to expanding URM representation in medicine reveals a repetitive, amplifying message of URM physician service commitment to vulnerable populations in medically underserved communities. Such message repetition reinforces policies and practices that might limit the full scope of URM practice, research and leadership opportunities in medicine. Cross-nationally, service commitment and patient-physician concordance benefits admittedly respond to recognised societal need, yet there is an associated risk for instrumentally singling out members of URMs to fulfil that need. The proceedings of a 2001 US Institute of Medicine symposium warned against creating a deterministic expectation that URM physicians provide care to minority populations. Our findings suggest that the expanding emphasis on URM service commitment and patient-physician concordance benefits warrants ongoing scrutiny and, more broadly, represent a cautionary tale of unintended consequences for medical educators globally.

Patterns of direct observation and their impact during residency: general practice supervisors' views.

Abstract: Context: Direct observation (DO) of residents’ performance, despite the importance that is ascribed to it, does not readily fit in with the practice of postgraduate medical education (PGME); it is infrequent and the quality of observation may be poor in spite of ongoing efforts towards improvement. In recent literature, DO is mostly portrayed as a means to gather information on the performance of residents for purposes of feedback and assessment. The role of DO in PGME is likely to be more complex and poorly understood in the era of outcome-based education. By exploring the possible complexity of DO in workplace learning, our research aims to contribute to a better use of DO in the practice of PGME. Methods: Constructivist grounded theory informed our data collection and analysis. Data collection involved focus group sessions with supervisors in Dutch general practice who were invited to discuss the manifestations, meanings and effects of DO of technical skills. Theoretical sufficiency was achieved after four focus groups, with a total of 28 participants being included. Results: We found four patterns of DO of technical skills: initial planned DO sessions; resident-initiated ad hoc DO; supervisor-initiated ad hoc DO, and continued planned DO sessions. Different patterns of DO related to varying meanings, such as checking or trusting, and effects, such as learning a new skill or experiencing emotional discomfort, all of them concerning the training relationship, patient safety or residents’ learning. Conclusions: Direct observation, to supervisors, means much more than gathering information for purposes of feedback and assessment. Planned DO sessions are an important routine during the initiation phase of a training relationship. Continued planned bidirectional DO sessions, although infrequently practised, potentially combine most benefits with least side-effects of DO. Ad hoc DO, although much relied upon, is often hampered by internal tensions in supervisors, residents or both.