Medicine as a Community of Practice: Implications for Medical Education

Transition to clinical practice during the COVID-19 pandemic: a qualitative study of young doctors' experiences in Brazil and Ireland

OBJECTIVES

To explore and compare the perspectives of junior doctors in Brazil and Ireland regarding transition and professional socialisation during the COVID-19 pandemic, with the purpose of identifying better ways to support doctors as they assume their new professional role.

DESIGN

27 semistructured interviews. Transcripts were analysed using qualitative thematic analysis. Cruess' framework of professional socialisation in medicine supported the interpretation of these data.

SETTING

Public health hospitals across four Brazilian states (Santa Catarina, São Paulo, Ceará, Paraíba) and County Cork in the South of Ireland.

PARTICIPANTS

Twenty-seven male and female medical junior doctors who had graduated between November 2019 and April 2020.

RESULTS

Fourteen Brazilian and 13 Irish junior doctors were interviewed for this study. Entry to clinical practice during the pandemic had a significant impact on factors influencing the professional socialisation of junior doctors. This impact was reflected across the following six thematic areas: lack of preparedness; disrupted trajectory of role adaptation; fewer opportunities for experiential learning; solidarity and isolation; altered interactions with patients; challenges to health and well-being.

CONCLUSIONS

Transition to clinical practice is an important stage in junior doctors' professional socialisation and identity formation. The COVID-19 pandemic created the opportunity for medical graduates to enter the workforce earlier than usual. Entering the workforce during this period created a lack of confidence among junior doctors concerning the boundaries of their new role and responsibilities, while simultaneously disrupting their social integration. Priorities to mitigate the impact of COVID-19 and future pandemics on this transition are presented.

Self-managed occupational therapy and physiotherapy for adults receiving inpatient rehabilitation ('My Therapy'): protocol for a stepped-wedge cluster randomised trial

BACKGROUND

Ensuring patients receive an effective dose of therapeutic exercises and activities is a significant challenge for inpatient rehabilitation. My Therapy is a self-management program which encourages independent practice of occupational therapy and physiotherapy exercises and activities, outside of supervised therapy sessions.

METHODS

This implementation trial aims to determine both the clinical effectiveness of My Therapy on the outcomes of function and health-related quality of life, and cost-effectiveness per minimal clinically important difference (MCID) in functional independence achieved and per quality adjusted life year (QALY) gained, compared to usual care. Using a stepped-wedge cluster randomised design, My Therapy will be implemented across eight rehabilitation wards (inpatient and home-based) within two public and two private Australian health networks, over 54-weeks. We will include 2,160 patients aged 18 + years receiving rehabilitation for any diagnosis. Each ward will transition from the usual care condition (control group receiving usual care) to the experimental condition (intervention group receiving My Therapy in addition to usual care) sequentially at six-week intervals. The primary clinical outcome is achievement of a MCID in the Functional Independence Measure (FIM™) at discharge. Secondary outcomes include improvement in quality of life (EQ-5D-5L) at discharge, length of stay, 30-day re-admissions, discharge accommodation, follow-up rehabilitation services and adverse events (falls). The economic outcomes are the cost-effectiveness per MCID in functional independence (FIM™) achieved and per QALY gained, for My Therapy compared to usual care, from a health-care sector perspective. Cost of implementation will also be reported. Clinical outcomes will be analysed via mixed-effects linear or logistic regression models, and economic outcomes will be analysed via incremental cost-effectiveness ratios.

DISCUSSION

The My Therapy implementation trial will determine the effect of adding self-management within inpatient rehabilitation care. The results may influence health service models of rehabilitation including recommendations for systemic change to the inpatient rehabilitation model of care to include self-management. Findings have the potential to improve patient function and quality of life, and the ability to participate in self-management. Potential health service benefits include reduced hospital length of stay, improved access to rehabilitation and reduced health service costs.

TRIAL REGISTRATION

This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000313831; registered 22/03/2021, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380828&isReview=true ).

Implementing work-related Mental health guidelines in general PRacticE (IMPRovE): a protocol for a hybrid III parallel cluster randomised controlled trial

BACKGROUND

The Clinical Guideline for the Diagnosis and Management of Work-related Mental Health Conditions in General Practice (the Guideline) was published in 2019. The objective of this trial is to implement the Guideline in general practice.

TRIAL DESIGN

Implementing work-related Mental health conditions in general PRacticE is a hybrid III, parallel cluster randomised controlled trial undertaken in Australia. Its primary aim is to assess the effectiveness of a complex intervention on the implementation of the Guideline in general practice. Secondary aims are to assess patient health and work outcomes, to evaluate the cost-effectiveness of the trial, and to develop a plan for sustainability.

METHODS

A total of 86 GP clusters will be randomly allocated either to the intervention arm, where they will receive a complex intervention comprising academic detailing, enrolment in a community of practice and resources, or to the control arm, where they will not receive the intervention. GP guideline concordance will be assessed at baseline and 9 months using virtual simulated patient scenarios. Patients who meet the eligibility criteria (>18years, employed, and receiving care from a participating GP for a suspected or confirmed work-related mental health condition) will be invited to complete surveys about their health and work participation and provide access to their health service use data. Data on health service use and work participation compensation claim data will be combined with measures of guideline concordance and patient outcomes to inform an economic evaluation. A realist evaluation will be conducted to inform the development of a plan for sustainability.

RESULTS

We anticipate that GPs who receive the intervention will have higher guideline concordance than GPs in the control group. We also anticipate that higher concordance will translate to better health and return-to-work outcomes for patients, as well as cost-savings to society.

CONCLUSIONS

The trial builds on a body of work defining the role of GPs in compensable injury, exploring their concerns, and developing evidence-based guidelines to address them. Implementation of these guidelines has the potential to deliver improvements in GP care, patient health, and return-to-work outcomes.

TRIAL REGISTRATION

ACTRN12620001163998 , November 2020.

Continuing Medical Education and Lifelong Learning

Continuing medical education is an ongoing process to educate clinicians and provide patients with up-to-date, evidence-based care. Since its inception, the maintenance of certification (MOC) program has changed dramatically. This article reviews the development of MOC and its integration with the 6 core competencies, including the practice-based learning and improvement cycle. The concept of lifelong learning is discussed, with specific focus on different methods for surgeons to engage in learning, including simulation, coaching, and communities of practice. In addition, the future of MOC in continuous professional development is reviewed.

Insights from a community-based palliative care course: a qualitative study

BACKGROUND

The vast majority of medical students have no exposure to clinical palliative care encounters, especially in the community. Medical schools should respond to current challenges and needs of health systems by guaranteeing students adequate training that addresses palliative care needs of populations in different settings. The main purpose of this qualitative study was to capture the experiences of a select group of medical students' following a community-based PC course.

METHODS

We carried out a qualitative study using two focus groups to capture the experience of medical students in a course that combined classroom teaching with community-based learning for undergraduate medical students in Germany. Discussions were transcribed and analyzed thematically.

RESULTS

Fifteen female students in their 2nd to 5th year participated in the focus groups, which provided didactic teaching and experiential learning. Four areas were particularly relevant: (1) authenticity, (2) demystification of the concepts of palliative care through personal contact with patients, (3) translation of theoretical knowledge into practice, and (4) observation of a role model interacting with seriously ill patients and engaging in difficult conversations.

CONCLUSION

Students whose encounters with patients and their families went beyond a review of their medical records had a better grasp of the holistic nature of PC than those who did not. Bringing students directly from the hospital to patients in their homes reinforced the benefits of an integrated healthcare system.

Postgraduate ethics training programs: a systematic scoping review

BACKGROUND

Molding competent clinicians capable of applying ethics principles in their practice is a challenging task, compounded by wide variations in the teaching and assessment of ethics in the postgraduate setting. Despite these differences, ethics training programs should recognise that the transition from medical students to healthcare professionals entails a longitudinal process where ethics knowledge, skills and identity continue to build and deepen over time with clinical exposure. A systematic scoping review is proposed to analyse current postgraduate medical ethics training and assessment programs in peer-reviewed literature to guide the development of a local physician training curriculum.

METHODS

With a constructivist perspective and relativist lens, this systematic scoping review on postgraduate medical ethics training and assessment will adopt the Systematic Evidence Based Approach (SEBA) to create a transparent and reproducible review.

RESULTS

The first search involving the teaching of ethics yielded 7669 abstracts with 573 full text articles evaluated and 66 articles included. The second search involving the assessment of ethics identified 9919 abstracts with 333 full text articles reviewed and 29 articles included. The themes identified from the two searches were the goals and objectives, content, pedagogy, enabling and limiting factors of teaching ethics and assessment modalities used. Despite inherent disparities in ethics training programs, they provide a platform for learners to apply knowledge, translating it to skill and eventually becoming part of the identity of the learner. Illustrating the longitudinal nature of ethics training, the spiral curriculum seamlessly integrates and fortifies prevailing ethical knowledge acquired in medical school with the layering of new specialty, clinical and research specific content in professional practice. Various assessment methods are employed with special mention of portfolios as a longitudinal assessment modality that showcase the impact of ethics training on the development of professional identity formation (PIF).

CONCLUSIONS

Our systematic scoping review has elicited key learning points in the teaching and assessment of ethics in the postgraduate setting. However, more research needs to be done on establishing Entrustable Professional Activities (EPA)s in ethics, with further exploration of the use of portfolios and key factors influencing its design, implementation and assessment of PIF and micro-credentialling in ethics practice.

[Education for resuscitation]

Diese Leitlinien des European Resuscitation Council basieren auf dem internationalen wissenschaftlichen Konsens 2020 zur kardiopulmonalen Reanimation mit Behandlungsempfehlungen (International Liaison Committee on Resuscitation 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations [ILCOR] 2020 CoSTR). Dieser Abschnitt bietet Bürgern und Angehörigen der Gesundheitsberufe Anleitungen zum Lehren und Lernen der Kenntnisse, der Fertigkeiten und der Einstellungen zur Reanimation mit dem Ziel, das Überleben von Patienten nach Kreislaufstillstand zu verbessern.

Some Learning Theories for Medical Educators

Perspectives on the nature of learning influence decisions about curriculum design, teaching and learning strategies, and assessment of students. Current literature on medical education suggests that medical teachers have much interest in using theories to inform their practice. This article describes the following learning theories that have been discussed to various degrees in previous literature on medical education: cognitivism, constructivism, experiential learning, adult learning, self-directed learning, community of practice and situated learning, cognitive apprenticeship, and reflective learning. Each theory is explained in sufficient detail to help readers grasp its essence. Then, medical education literature is cited to show how the theory has been used or can be used to guide practice in medical education. Finally, this article analyzes the problem-based learning approach as an example to illustrate how the theories may be reflected in practice. Throughout the introduction of the various theories, this article aims at their application in medical education and attempts to draw connections among the theories rather than represent them as unrelated or competing ideas.

Adult Gastroenterology Trainees’ Experience of Receiving Feedback on Their Performance of Endoscopy in the Workplace

Background

Competency-based gastrointestinal endoscopy training is concerned with outcomes of the learning experience. Feedback allows for trainees to achieve the expected outcomes. However, little is known about trainees’ experience of receiving feedback. Gaining understanding of their experience could help improve feedback practices. The study was conducted to explore what it means for adult gastroenterology trainees to receive feedback on their performance of endoscopy in the workplace.

Methods

An interpretative phenomenological approach was used. Individual semi-structured interviews were conducted with six trainees from three Canadian adult gastroenterology residency programs. Interviews were audio-recorded and transcribed verbatim for analysis. Analysis was conducted to identify the phenomenological themes across participants’ accounts of lived experience to provide an insight into the meaning of experiencing the studied phenomenon.

Findings

Three phenomenological themes of experience were identified: taking pauses, negotiating understandings and accepting asymmetry. Taking pauses allowed for participants to receive feedback on their performance of endoscopy. Participants needed to negotiate attending gastroenterologists’ different understandings of gastrointestinal endoscopy while carrying their own whenever feedback was provided. They had to accept the asymmetry between the roles of care provider and learner as well.

Discussion

The study has captured the uniqueness and the complexity of the lived experience of receiving feedback on the performance of endoscopy in the workplace from the perspective of study participants. The gained understanding of this experience has enabled the authors to suggest how attending gastroenterologists’ feedback practices may be improved.

Qualitative exploration of medical student experiences during the Covid-19 pandemic: implications for medical education

BACKGROUND

During the Covid-19 pandemic medical students were offered paid roles as medical student healthcare assistants. Anecdotal reports suggested that students found this experience rich for learning. Previous studies have explored alternative models of student service, however this defined medical student support role is novel.

METHODS

Individual semi-structured interviews were recorded with 20 medical students at a UK medical school exploring their experiences of placement learning and experiences of working as healthcare assistants. Responses were analysed qualitatively using a framework approach. The framework was developed into a model describing key findings and their relationships.

RESULTS

Interviews yielded data that broadly covered aspects of (1) Medical students' experiences of clinical placement learning (2) Medical students' experiences of working as medical student healthcare assistants (3) Learning resulting from working as a healthcare assistant (4) Hierarchies and professional barriers in the clinical environment (5) Influences on professional identity. Participants described barriers and facilitators of clinical learning and how assuming a healthcare assistant role impacted on learning and socialisation within the multidisciplinary team. Students became increasingly socialised within the healthcare team, contributing directly to patient care; the resulting social capital opened new opportunities for learning, team working and enhanced students' interprofessional identity. Students described the impact of these experiences on their aspirations for their future practice.

CONCLUSIONS

Changes to work patterns in healthcare and delivery models of medical education have eroded opportunities for students to contribute to healthcare delivery and be embedded within a team. This is impacting negatively on student learning and socialisation and we suggest that medical curricula have much to learn from nursing and allied health professional training. Longitudinal embedment with a multidisciplinary team, where students have a defined role and work directly with patients may not only add value to clinical service, but also overcome current barriers to effective placement learning and interprofessional identity formation for medical students.

Acceptability of a complex team-based quality improvement intervention for transient ischemic attack: a mixed-methods study

BACKGROUND

The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability.

METHODS

QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA).

RESULTS

Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team's self-efficacy to improve quality of care. Guided by the TFA, the QI teams' acceptability was represented by the respective seven components of the multifaceted acceptability construct.

CONCLUSIONS

Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization.

TRIAL REGISTRATION

clinicaltrials.gov : NCT02769338 .

Advancing quality culture in health professions education: experiences and perspectives of educational leaders

The concept of quality culture has gained increased attention in health professions education, drawing on insights that quality management processes and positive work-related attitudes of staff in synergy lead to continuous improvement. However, the directions that guide institutions from quality culture theory to educational practice have been missing so far. A prospective qualitative case study of three health professions education programmes was conducted to explore how a quality culture can be enhanced according to the experiences and perspectives of educational leaders. The data collection was structured by an appreciative inquiry approach, supported with vignette-based interviews. A total of 25 participants (a selection of course coordinators, bachelor coordinators and directors of education) reflected on quality culture themes to learn about the best of what is (Discover), envision positive future developments (Dream), identify actions to reach the desired future (Design), and determine how to support and sustain improvement actions (Destiny) within their own educational setting. The results are presented as themes subsumed under these four phases. The experiences and perspectives of educational leaders reveal that peer learning in teams and communities, attention to professional development, and embedding support- and innovation networks, are at the heart of quality culture enhancement. An emphasis on human resources, (inter)relations and contextual awareness of leaders stood out as quality culture catalysts. Educational leaders are therefore encouraged to especially fuel their networking, communication, coalition building, and reflection competencies.

European Resuscitation Council Guidelines 2021: Education for resuscitation

These European Resuscitation Council education guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.

Conducting of Web-Based Workshops for Final Year Medical Students Preparing to Enter the Workforce During the COVID-19 Pandemic

Medical students were temporarily removed from direct patient contact activities during the COVID-19 pandemic, shortening the duration of ward-based attachment programs. Web-based workshops were organized to equip final year medical students with necessary skills to start work in a general medicine setting. Topics included case-based scenarios reviewing patients with new complaints, medical documentation, and inter-professional communication. They were conducted using an online video conference platform and utilized polling platforms, small group discussions, and the "Chat" function to promote interactivity. Web-based learning enables delivery of useful contents without compromising interactivity and clinical applicability during the COVID-19 pandemic.

Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack

BACKGROUND

The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA).

OBJECTIVE

We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019).

DESIGN

A stepped-wedge implementation trial with six geographically diverse sites.

PARTICIPANTS

The six facility QI teams were multi-disciplinary, clinical staff.

INTERVENTIONS

PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback.

MAIN MEASURES

Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year.

KEY RESULTS

Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation.

CONCLUSIONS

The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02769338.

Supporting a teacher identity in health professions education: AMEE Guide No. 132

This guide provides an understanding of what teacher identity is and how it can be developed and supported. Developing a strong teacher identity in the context of health professions education is challenging, because teachers combine multiple roles and the environment usually is more supportive to the identity of health practitioner or researcher than to that of teacher. This causes tensions for those with a teaching role. However, a strong teacher identity is important because it enhances teachers' intention to stay in health professions education, their willingness to invest in faculty development, and their enjoyment of the teaching role. The guide offers recommendations on how to establish workplace environments that support teacher identity rather than marginalise it. Additionally, the guide offers recommendations for establishing faculty development approaches that are sensitive to teacher identity issues. Finally, the guide provides suggestions for individual teachers in relation to what they can do themselves to nurture it.

Developing a community of practice for quality assurance within healthcare assessment

BACKGROUND

The Australian Collaboration for Clinical Assessment in Medicine (ACCLAiM) is a voluntary assessment consortium, involving medical schools nationwide. The aims of ACCLAiM are to benchmark student clinical assessment outcomes and to provide quality assurance (QA) of exit-level Objective Structured Clinical Exams (OSCEs). This study aimed to evaluate the impact of the ACCLAiM QA process for optimising OSCE delivery standards at the member schools using a Community of Practice (CoP) framework.

METHODS

A mixed methods sequential explanatory design, involving an online questionnaire and subsequent focus group discussions, was utilised. Questionnaire responses were analysed using descriptive statistics, while thematic analysis was employed for the qualitative data.

RESULTS

Data analysis revealed that school-specific OSCE practices had evolved based on QA feedback, as well as a collaborative sharing of expertise consistent with a CoP model. Extending beyond a QA working group for accountability and demonstration of minimum standards, participation in ACCLAiM QA processes is creating a sustainable socio-academic network focused on quality improvement.

CONCLUSION

Collaborative QA in clinical assessment creates opportunities for optimising standards in OSCE processes and sharing of resources for OSCE assessments. It also allows for professional development and scholarly engagement in assessment research. These benefits contribute to the existence of an emergent CoP model.

Learning to Critically Appraise Rheumatic Disease Literature: Educational Opportunities During Training and into Practice

To provide optimal patient care, rheumatologists must be equipped and motivated to critically appraise the literature. The conceptual frameworks Retrieval Enhanced Learning, Self-Determination Theory, and Communities of Practice can inform the design of educational approaches to promote critical appraisal in practice. HSS CLASS-Rheum® is a learning tool that can be used to help rheumatologists learn skills for critical appraisal through retrieval practice. Combining retrieval practice with opportunities for connection through Peer Instruction, journal clubs, and other forums can help support engagement and internalization of motivation, promoting persistence with critical appraisal in practice.

A Call for Curriculum and Faculty Developers to Attend to Ambitious Teaching in Experiential Curriculum

To realize the goals of an experiential curriculum, medical educators need support to enact a different kind of teaching: ambitious teaching. Ambitious teaching promotes curricular aims and fosters responsive, interactive environments to elicit student thinking and facilitate student-to-student discussion of clinical concepts and reasoning. The purpose of this article is to provide a framework for ambitious teaching that can be used to meet the complex challenges of experiential learning. Specifically, we describe the ways in which medical education curriculum and faculty developers can support ambitious teaching and, ultimately, enhance curricular outcomes.

Level of clinical reasoning in intermediate nursing students explained by education year and days of internships per healthcare branches: A cross - sectional study

BACKGROUND

Due to changes in health care nurses are achieving more responsibilities. Globally nurses are trained at different educational levels to become registered nurses. All nurses should be able to implement clinical reasoning in chronic and acute patient care. There is uncertainty in health care institutes about the level of performance of clinical reasoning in the intermediate nurses.

OBJECTIVES

This cross-sectional study aimed to assess the level of clinical reasoning in intermediate nursing students in different education years. Furthermore, we explored whether the level of clinical reasoning can be explained by years of education and numbers of internship days in different healthcare settings.

DESIGN, SETTING AND PARTICIPANTS

All second, third and fourth year (n = 151) nursing students of one nursing school in the Netherlands were invited to participate in this study. Levels of clinical reasoning were assessed using the Dutch Lasater Clinical Judgment Rubric (D - LCJR).

METHODS

Twelve experienced nurses assessed the students during two days at the beginning of their education year in an educational simulation setting. Following the assessment protocol, the Rubric was scored in an interview after the students saw their patient.

RESULTS

We assessed 119 students. Fourth-year students scored on a significant higher level of clinical reasoning compared to the second - and third-year students (p < 0.001). Forty five percent of them reached an accomplished level of clinical reasoning. Second- and third-year students scored similar in their level of clinical reasoning (p = 0.61). In addition to education year an internship in the hospital care also explained the variation in level of clinical reasoning. Together they explained 38% (p < 0.001).

CONCLUSIONS

Intermediate nursing students were successfully assessed on their level of clinical reasoning in an education environment. The level of clinical reasoning could be explained by education year and number of days internship in the hospital care.

Science Bootcamp Goes Virtual: a Compressed, Interdisciplinary Online CURE Promotes Psychosocial Gains in STEM Transfer Students

Course-based undergraduate research experiences (CUREs) are well-documented as high-impact practices that can broaden participation and success in STEM. Drawing primarily from a community of practice theoretical framework, we previously developed an interdisciplinary CURE course (Science Bootcamp) for STEM majors focused entirely on the scientific process. Among first-year students, Science Bootcamp leads to psychosocial gains and increased retention. In the current study, we test whether an online Science Bootcamp also improved outcomes for STEM transfer students-a group that faces "transfer shock," which can negatively impact GPA, psychosocial outcomes, and retention. To this end, we redesigned Science Bootcamp to a 2-week course for STEM transfer students to complete prior to beginning the fall semester at our 4-year institution. Due to the COVID-19 pandemic, the course was conducted in an entirely virtual format, using primarily synchronous instruction. Despite the course being virtual, the diverse group of STEM majors worked in small groups to conduct rigorous, novel empirical research projects from start to finish, even presenting their results in a poster symposium. Assessment data confirmed the compressed, online Science Bootcamp contained key CURE components-opportunities for collaboration, discovery and relevance, and iteration-and that students were highly satisfied with the course. Moreover, in line with our hypothesis, STEM transfer students who participated in the online Science Bootcamp experienced a range of psychosocial gains (e.g., belonging to STEM). In sum, these findings suggest our online Science Bootcamp promotes positive STEM outcomes, representing a highly flexible and affordable CURE that can be scaled for use at institutions of any size.

Calibration Bias and the Interpretation of Clinical Learning Environment Perceptions Surveys

BACKGROUND

The clinical learning environment (CLE) is frequently assessed using perceptions surveys, such as the AAMC Graduation Questionnaire and ACGME Resident/Fellow Survey. However, these survey responses often capture subjective factors not directly related to the trainee's CLE experiences.

OBJECTIVE

The authors aimed to assess these subjective factors as "calibration bias" and show how it varies by health professions education discipline, and co-varies by program, patient-mix, and trainee factors.

METHODS

We measured calibration bias using 2011-2017 US Department of Veterans Affairs (VA) Learners' Perceptions Survey data to compare medical students and physician residents and fellows (n = 32 830) with nursing (n = 29 758) and allied and associated health (n = 27 092) trainees.

RESULTS

Compared to their physician counterparts, nursing trainees (OR 1.31, 95% CI 1.22-1.40) and allied/associated health trainees (1.18, 1.12-1.24) tended to overrate their CLE experiences. Across disciplines, respondents tended to overrate CLEs when reporting 1 higher level (of 5) of psychological safety (3.62, 3.52-3.73), 1 SD more time in the CLE (1.05, 1.04-1.07), female gender (1.13, 1.10-1.16), 1 of 7 lower academic level (0.95, 1.04-1.07), and having seen the lowest tercile of patients for their respective discipline who lacked social support (1.16, 1.12-1.21) and had low income (1.05, 1.01-1.09), co-occurring addictions (1.06, 1.02-1.10), and mental illness (1.06, 1.02-1.10).

CONCLUSIONS

Accounting for calibration bias when using perception survey scores is important to better understand physician trainees and the complex clinical learning environments in which they train.

Descriptions and Reflections on the Cognitive Apprenticeship Model of Psychotherapy Training & Supervision

This paper offers a detailed description of a Cognitive Apprenticeship Model for psychotherapy training and supervision. This form of training has been utilized in a novel psychotherapy training program developed for psychiatric trainees, enrolled in a specialized psychotherapy scholars track, embedded in an adult psychiatric residency training program. The paper offers new elaborations of the model, reflections on the apprenticeship supervision and implementation, and clinical lessons learned. The four dimensions of this model include: (1) acquisition of psychotherapy content knowledge; (2) an application of the Cognitive Apprenticeship Model of Supervision, utilizing modeling, coaching, scaffolding, articulation, reflection and exploration as essential aids in structuring a live, real-time supervisory experience; (3) sequencing of clinical psychotherapy training activities; and (4) use of situated learning and communities of practice, as important components of psychotherapy training. The article also discusses an apprentice method of psychotherapy supervision including the intake, working through, and termination phases, Barriers impeding apprenticeship supervision and implementation, and reflections on participant experiences are discussed. This approach may be valuable to others considering the development or evolution of psychotherapy training programs for psychiatrists, psychologists, social workers, or other mental health professionals.

First year medical students' perceptions of the impact of wearing scrubs on professional identity: a narrative analysis in the United Arab Emirates

OBJECTIVES

Medical school serves as a critical developmental period for future physicians, during which students begin to form a professional identity. Just as personal appearance, particularly clothing, is an important external expression of one's personal identity, 'uniforms' in healthcare, including white coats and scrubs, symbolise status and a group identity. There are, however, limited studies on the impact of physician attire on medical students' formation of professional identity. Accordingly, through qualitative analysis of written narratives, we sought to analyse medical students' experiences of wearing professional physician attire, namely scrubs, and how the uniform impacted their confidence level, performance and behaviours, as well as their identity as future physicians.

DESIGN

Qualitative analysis of medical student's written narratives.

SETTING

Khalifa University College of Medicine and Health Sciences (KU CMHS) is a new medical school in the United Arab Emirates, with an inaugural class of 30 students admitted in August 2019. It is the only medical school in the city of Abu Dhabi, and the only school in the country that follows a postgraduate medical curriculum.

PARTICIPANTS

All first year medical students at KU CMHS were purposively sampled.

METHODS

Students completed a voluntary online anonymous questionnaire. We employed a social identity approach to data analysis. Thematic content analysis was conducted on their narratives to identify themes.

RESULTS

We identified three major themes, namely (1) emotions, (2) logistics and (3) interpersonal relationships.

CONCLUSIONS

Medical students form early perceptions regarding physician attire and its impact on their professional identity. Engaging in conversations regarding professional attire with educators or mentors could provide an important opportunity for students to discuss and explore professional identity early in training.

"Can virtue be taught?": a content analysis of medical students' opinions of the professional and ethical challenges to their professional identity formation

BACKGROUND

Efforts have begun to characterize the ethical and professional issues encountered by medical students in their clinical years. By applying previously identified taxonomies to a national sample of medical students, this study seeks to develop generalizable insights that can inform professional identity formation across various clerkships and medical institutions.

METHODS

In a national survey of medical students, participants answered an open-ended survey item that asked them to describe a clinical experience involving an ethical or professional issue. We conducted a content analysis with these responses using the Kaldjian taxonomy of ethical and professionalism themes in medical education through an iterative, consensus-building process. Noting the emerging virtues-based approach to ethics and professionalism, we also reexamined the data using a taxonomy of virtues.

RESULTS

The response rate to this survey item was 144 out of 499 eligible respondents (28.9%). All 144 responses were successfully coded under one or more themes in the original taxonomy of ethical and professional issues, resulting in a total of 173 coded responses. Professional duties was the most frequently coded theme (29.2%), followed by Communication (26.4%), Quality of care (18.8%), Student-specific issues of moral distress (16.7%), Decisions regarding treatment (16.0%), and Justice (13.2%). In the virtues taxonomy, 180 total responses were coded from the 144 original responses, and the most frequent virtue coded was Wisdom (23.6%), followed by Respectfulness (20.1%) and Compassion or Empathy (13.9%).

CONCLUSIONS

Originally developed from students' clinical experiences in one institution, the Kaldjian taxonomy appears to serve as a useful analytical framework for categorizing a variety of clinical experiences faced by a national sample of medical students. This study also supports the development of virtue-based programs that focus on cultivating the virtue of wisdom in the practice of medicine.

An Inter-Institutional External Peer-Review Process to Evaluate Educators at Schools of Veterinary Medicine

Despite its fundamental importance, the educational mission of most schools of veterinary medicine receives far less recognition and support than the missions of research and discovery. This disparity is evident in promotion and tenure processes. Despite the frequent assertion that education is every college's core mission, there is a broad consensus that faculty are promoted primarily on the basis of meeting expectations relative to publications and grant funding. This expectation is evident in the promotion packets faculty are expected to produce and the criteria by which those packets are reviewed. Among the outcomes is increasing difficulty in hiring and retaining faculty, including young clinicians and basic scientists who are drawn to academic institutions because of the opportunity to teach. The Regional Teaching Academy (RTA) of the West Region Consortium of Colleges of Veterinary Medicine initiated an inter-institutional collaboration to address the most important obstacles to recognizing and rewarding teaching in its five member colleges. Working from the medical education literature, the RTA developed an Educator's Promotion Dossier, workshops to train promotion applicants, and an external review process. Initial use has shown that the reviews are efficient and complete. Administrators have expressed strong support for the product, a letter of external review that is returned to a promotion applicant's home institution. The overall result is an evidence-based, structured process by which teaching-intensive faculty can more fully document their achievements in teaching and educational leadership and a more rigorous external review process by which member colleges can assess quality, impact, and scholarly approach.

Clinical Teachers' Perceptions of Their Role in Professional Identity Formation

PURPOSE

A fundamental goal of medical education is supporting learners in forming a professional identity. While it is known that learners perceive clinical teachers to be critically important in this process, the latter's perspective is unknown. This study sought to understand how clinical teachers perceive their influence on the professional identity formation of learners.

METHOD

In 2017, a research assistant conducted 16 semistructured interviews of clinical teachers from 8 specialties at McGill University. The research assistant audiorecorded and subsequently transcribed interviews for analysis. Following principles of qualitative description, the research team developed a coding scheme using both inductive codes (from the words of the participants) and deductive codes (based on the literature and the theory of communities of practice). Through a cross-case analysis, the team then identified salient themes.

RESULTS

Participants struggled to describe their influence on learners' professional identity without first being prompted to focus on their own identity and its formation. Once prompted, clinical teachers reported viewing their personal and professional identities as integrated and believed that caring for patients was integral to forming their professional identity. They identified explicit role modeling, engaging in difficult conversations, and providing graded autonomy as ways in which they could influence the identity development of learners. However, they had difficulty discerning the magnitude of their influence.

CONCLUSIONS

This study was the first to explore professional identity formation from the perspective of clinical teachers. The 2010 Carnegie Foundation report called for an increased focus on professional identity formation. Giving clinical teachers the space and guidance to reflect on this process, helping them make the implicit explicit, and supporting them in using their own experiences as learners to inform their teaching appear to be critical steps in achieving this goal.

Coaching Versus Competency to Facilitate Professional Identity Formation

Professional identity formation, with its focus on the development of professional values, actions, and aspirations, is the ideal goal of medical education. Medicine is a community of practice, and medical education is a socialization process by which novice trainees become full community members. The authors believe coaching provides an ideal means for promoting this socialization process to develop a learner's identity as they engage in the community. Coaching involves an orientation toward growth and development, valuing reflection and nurturing continuous reflection, and embracing failure as an opportunity for learning. However, there are challenges to implementing coaching in medical education. Competency-based medical education has provided clear outcomes (competencies) for medical education and programs of assessment around these competencies. Yet, there is a tension in medical training between professional identity formation (the process of socialization into the profession) and the formal assessment process. The ideal of multiple low-stakes assessments and written evaluations, intended as formative assessments, are perceived by residents as high-stakes evaluations with significant consequences for their future. The authors present a resident story that highlights this tension. They outline Goffman's theory of impression management, postulating that medicine's assessment system encourages residents to stage a performance for evaluators that displays their competence and conceals their perceived weaknesses. This performance hinders coaching and the formation of an appropriate professional identity. Coaching, the authors believe, provides a model that aligns assessment and professional identity formation. Given the challenges to implementing coaching in medical education, the authors propose several questions to contemplate when integrating coaching into medical education to facilitate the goal of professional identity formation.

What Does Context Have to Do With Anything? A Study of Professional Identity Formation in Physician-Trainees Considered Underrepresented in Medicine

PURPOSE

Research on professional identity formation has largely ignored how race, ethnicity, and the larger sociohistorical context work to shape medical students' professional identity. Researchers investigated how physician-trainees considered underrepresented in medicine (URM) negotiate their professional identity within the larger sociohistorical context that casts them in a negative light.

METHOD

In this qualitative study, 14 black/African American medical students were recruited from the Medical College of Georgia at Augusta University and Emory University College of Medicine between September 2018 and April 2019. Using constructive grounded theory and Swann's model of identity negotiation, the authors analyzed interview data for how students negotiate their racial and professional identities within medical education.

RESULTS

The results indicated that URM students were aware of the negative stereotypes ascribed to black individuals and the potential for the medical community to view them negatively. In response, students employed identity cues and strategies to bring the community's perceptions in line with how they perceived themselves-black and a physician. Specifically, students actively worked to integrate their racial and professional identities by "giving back" to the African American community. Community-initiated mentoring from non-URM physicians helped to reify students' hope that they could have a racialized professional identity.

CONCLUSIONS

Race, ethnicity, and the larger sociohistorical context is often overlooked in professional identity formation research, and this omission has resulted in an underappreciation of the challenges URM physicians' experience as they develop a professional identity. Within the context of this study, findings demonstrated that black/African American physicians negotiated the formation of professional identity within a challenging sociohistorical context, which should be given greater consideration in related research.

Interprofessional education and collaboration between general practitioner trainees and practice nurses in providing chronic care; a qualitative study

BACKGROUND

Effective interprofessional collaboration (IPC) is essential for the delivery of chronic care. Interprofessional education (IPE) can help support IPC skills. This makes IPE interesting for GP practices where chronic care is delivered by GPs together with practice nurses, especially for GP trainees who have to learn to collaborate with practice nurses during their training. The aim of this study is to gain insights in how IPE and IPC occur between GP trainees and practice nurses during the delivery of chronic care in GP training practices.

METHODS

We conducted a qualitative research using semi structured focus groups and interviews with GP trainees, practice nurses and GP supervisors. All respondents were primed to the subject of IPE as they had followed an interprofessional training on patient-centred communication. The verbatim transcripts of the focus groups and interviews were analysed using thematic analysis.

RESULTS

Despite the overall positive attitude displayed by respondents towards IPE and IPC, the occurrence of IPE and IPC in GP training practices was limited. Possible explanations for this are impeding factors such as limited knowledge, prejudice, lack of role models and a hierarchical organisational structure. Contributing to IPE and IPC use was the integration of IPE in daily practice, e.g. via recurring scheduled meetings.

CONCLUSION

We found a limited occurrence of IPE and IPC in GP training practices. Our results show a discrepancy between respondents enthusiasm for IPE and IPC and their actual behaviour. IPE activities have to be initiated in GP training practices, otherwise, despite good intentions, IPE and IPC will be ineffective.

Journey into uncertainty: Medical students' experiences and perceptions of failure

CONTEXT

Having succeeded in being selected for medical school, medical students are not always familiar with failure and yet they are expected to graduate prepared to effectively function in the failure-burdened arena of clinical medicine. Lacking in the developing literature on learners and failure is an exploration of how this transformation is accomplished. The purpose of this study was to examine how medical students perceive and experience failure during their medical school training.

METHOD

We used a qualitative description methodology to probe the failure experiences of medical students attending a Canadian medical school. Participants were provided with the broad definition of failure used in this research: 'deviation from expected and desired results.'In total, 12 students were sampled, three from each of the 4 years of study, and participated in individual, semi-structured interviews that were analysed using thematic analysis to identify and describe core themes.

RESULTS

At the start of medical school, students admitted limited experience with failure; their early descriptions were self-centred and binary. Personal stories recounted by preceptors encouraged students and helped them understand that physicians are human and that failure is inevitable. Students felt relatively protected from failures that could impact patients. Both witnessing and participating in a failure event were distressing and sometimes at odds with their expectations. Students expressed a desire to talk about the experience.

CONCLUSIONS

Medical students described examples of experiencing failure during medical school that transported them from the more certain black and white beginnings of their classroom into the uncertain shades of grey of clinical medicine. What the participants heard, saw and experienced suggests opportunities for classroom teachers to better prepare pre-clinical students for the inevitability of failure in clinical medicine and opportunities for clinical teachers to engage in open, inclusive conversations surrounding failures that occur on their watch.

Autonomy and professional identity formation in residency training: A qualitative study

CONTEXT

Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training.

METHODS

Using constructivist grounded theory, we conducted 23 semi-structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de-identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data.

RESULTS

Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making 'real decisions' for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care.

CONCLUSIONS

This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety.

Development of an in situ simulation-based continuing professional development curriculum in pediatric emergency medicine

BACKGROUND

Continuing professional development (CPD) activities delivered by simulation to independently practicing physicians are becoming increasingly popular. At present, the educational potential of such simulations is limited by the inability to create effective curricula for the CPD audience. In contrast to medical trainees, CPD activities lack pre-defined learning expectations and, instead, emphasize self-directed learning, which may not encompass true learning needs. We hypothesize that we could generate an interprofessional CPD simulation curriculum for practicing pediatric emergency medicine (PEM) physicians in a single-center tertiary care hospital using a deliberative approach combined with Kern's six-step method of curriculum development.

METHODS

From a comprehensive core list of 94 possible PEM clinical presentations and procedures, we generated an 18-scenario CPD simulation curriculum. We conducted a comprehensive perceived and unperceived needs assessment on topics to include, incorporating opinions of faculty PEM physicians, hospital leadership, interprofessional colleagues, and expert opinion on patient benefit, simulation feasibility, and value of simulating the case for learning. To systematically rank items while balancing the needs of all stakeholders, we used a prioritization matrix to generate objective "priority scores." These scores were used by CPD planners to deliberately determine the simulation curriculum contents.

RESULTS

We describe a novel three-step CPD simulation curriculum design method involving (1) systematic and deliberate needs assessment, (2) systematic prioritization, and (3) curriculum synthesis. Of practicing PEM physicians, 17/20 responded to the perceived learning needs survey, while 6/6 leaders responded to the unperceived needs assessment. These ranked data were input to a five-variable prioritization matrix generating priority scores. Based on local needs, the highest 18 scoring clinical presentations and procedures were selected for final inclusion in a PEM CPD simulation curriculum. An interim survey of PEM physician (21/24 respondents) opinions was collected, with 90% finding educational value with the curriculum. The curriculum includes items not identified by self-directed learning that PEM physicians thought should be included.

CONCLUSIONS

We highlight a novel methodology for PEM physicians that can be adapted by other specialities when designing their own CPD simulation curriculum. This methodology objectively considers and prioritizes the needs of practicing physicians and stakeholders involved in CPD.

Transition Task Force: Early efforts towards comprehensive pediatric to adult transition services in an academic medical center

Background

The process of transitioning from a pediatric to adult health models of care is a significant challenge associated with heightened morbidity and mortality, particularly for patients with medical complexity.

Methods

Our institution has no formal standardized transition services for patients transitioning from pediatric to adult models of care. The Transition Task Force was created as a community of practice to support interprofessional teams in creating a standard, yet individualized, approach to pediatric to adult transition across multiple departments of an academic center.

Results

The Transition Task Force has been meeting for approximately 4 years, and almost three-quarters of participants report that participation resulted in changes to their clinical process, in spite of recognition of common barriers to effective transition.

Conclusions

The development of a transition-focused community of practice can effectively support implementation of quality improvement projects collaboratively in both a standardized and individualized fashion.

A Robust Faculty Development Program for Medical Educators: A Decade of Experience

OBJECTIVES

Faculty development programs (FDPs) foster learning communities and enhance professional identity formation for medical educators. Competency-based frameworks for faculty development drive skill development across clinical practice, teaching, and scholarship domains. The aims of this study are to outline the context, content, and evolution of a novel FDP; map the individual conferences that make up the FDP to established faculty development competencies; identify steps to implement similar programming; and demonstrate outcomes to date.

METHODS

The FDP consists of four, 1-hour-long conferences held weekly on a rotating basis since 2007 at the University of Pittsburgh School of Medicine: Academy of Master Educators, Medical Education Research, Medical Education Journal Club, and Medical Education Research Methods and Innovative Design conference. Authors outline the relation of each of these four conferences to faculty development competencies and describe early outcomes for each conference over four consecutive academic years from 2014 to 2018. Participants include attendees and presenters in four consecutive academic years from 2014 to 2018.

RESULTS

The well-attended FDP meets all established competencies for educator faculty. Presenters and attendees were diverse in terms of academic rank and represented a breadth of clinical and basic science specialties.

CONCLUSIONS

This integrated FDP fosters a community of medical educators and develops faculty skills across established medical educator competencies.

Training junior faculty to become clinical teachers: The value of personalized coaching

Background: Junior clinical faculty require institutional support in the acquisition of feedback and clinical supervision skills of trainees. We tested the effectiveness of a personalized coaching versus guided self-reflection format of a faculty development program at improving faculty skills and self-efficacy.Methods: Participants were evaluated both before and after the program using a four-station Objective Structured Teaching Exercise (OSTE). A gain-score analysis, one-way ANOVA, and paired t-tests were used to evaluate both groups. The impact on the learning environment was measured by resident ratings of the Maastricht Clinical Teaching Questionnaire.Results: One hundred and twenty-seven participants completed the study over a three-year period. Both groups had significant improvements in self-efficacy. Participants in the coaching group demonstrated superior performance in encouraging learner self-reflection, teaching effectiveness, verifying learner understanding, exploring feelings/needs, and defining learning objectives. Over a 5-year period, the overall institutional learning climate significantly improved concerning faculty role-modeling, coaching, articulation, and explorations skills.Conclusion: Offering a contextualized faculty-development program using OSTEs that provides multiple opportunities for feedback and is focused on creating a community of practice is an effective method to facilitate the transfer of skills to the clinical environment, supports teacher identity development, and favorably impacts the learning climate.

Supervision of Resident Physicians

Supervision of resident physicians is a high-risk area of emergency medicine, and what constitutes appropriate supervision is a complex question. In this article, policies and procedures for appropriate supervision of resident physicians and the implications for billing are reviewed. Recommendations on supervision of resident physicians in the emergency department are detailed, with attention paid to addressing challenges in balancing patient safety with resident autonomy and education during the course of patient care and graduate medical education.

Situated learning theory in health professions education research: a scoping review

At a time when cognitive and behavioral theories dominated the landscape of learning theories, Lave and Wenger's situated learning theory (SLT) opened new territory by illuminating social and cultural learning processes. Many researchers and educators in the health professions embraced this theory, but few have considered how SLT has been used and what has been learned or improved through its use in health professions education (HPE). In this scoping review, the authors examine these questions and consider opportunities for future work with SLT in HPE. The authors followed Levac's modified scoping review framework. They conducted a search of CINAHL, ERIC, PubMed, Scopus, and Web of Science for articles referencing SLT or related concepts in HPE between 2006 and 2016. Two reviewers screened all titles and abstracts, then screened full text for inclusion based on substantive treatment of SLT. Two authors extracted, analyzed and synthesized data from the final set of 193 articles. The authors identified two patterns of theory use. One sought an understanding of social learning processes in a specific context. The other aimed to design and/or evaluate interventions associated with communities of practice. These patterns are similar to other literatures (e.g., general education, healthcare, and organizational development) and, according to Lave and Wenger, may reflect confusion about the purpose, stance, and terminology of SLT. The authors discuss their findings in relation to primary source literature and consider opportunities for HPE researchers to employ and contribute to SLT going forward.

Cancer Survivorship Care Roles for Primary Care Physicians

PURPOSE

Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors.

METHODS

We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process.

RESULTS

Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge.

CONCLUSIONS

This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.

A professionalism program in medical education and training - From broad values to specific applications: YLL School of Medicine, Singapore

The process for introducing and developing a program for teaching medical professionalism at the National University of Singapore, School of Medicine is outlined. Professionalism was recognised as embracing 'honesty and integrity,' 'responsibility and participation,' 'respect and sensitivity,' and 'compassion and empathy.' Those broad values are expressed as specific attitudes and behaviours that are taught and assessed throughout the course. Honesty and integrity, for example, are demonstrated by 'presenting original, authentic assignments' (in medical education); and 'accepting personal mistakes and honestly acknowledging them' (in clinical training and practice). Values and items of behaviour were drawn from the literature, and reviewed and refined to address needs identified within the Medical School. A broad spectrum of pre-clinical and clinical teachers contributed to this development. The program was reassessed to determine the extent to which it has been implemented and has evolved following its adoption. The results are confirming in that: the majority of recommendations have been implemented; the program has developed further; and is supported by ancillary student enrichment activities. Medical professionalism has been given prominence through all phases of the course. Nevertheless, challenges remain and particularly in the extent to which medical professionalism is taught and assessed in various clinical postings.

You say it, we say it, but how do we use it? Communities of practice: A critical analysis

OBJECTIVES

As educational theories are increasingly used in medical education research there are concerns over how these theories are used, how well they are presented and what the authors intend. Communities of practice (CoP) is one example of an often-used theory and conceptual framework. This paper presents a critical analysis of how CoP theory is used in medical education research.

METHODS

A critical literature analysis was undertaken of articles published between 1998 and 2018 in eight internationally recognised medical education journals. From a total of 541 articles, 80 articles met the inclusion criteria and were analysed and mapped according to various patterns of use.

RESULTS

We discerned five categories of use, two misleading and cosmetic, off target and cosmeticising, and three functional, framing, lensing and transferring. A considerable number of articles either misrepresented the point of communities of practice or used it in a cosmetic fashion. The remainder used the theory to frame an ongoing study in relation to other work, as a lens through which to design the study and collect or analyse data, or as a way of discussing or demonstrating the transferability of the findings.

CONCLUSIONS

We conclude that almost half of the reviewed articles did not offer a functional and rigorous definition of what is meant by CoP; instead, they used it in a potentially misleading or cosmetic manner. This study therefore calls on editors, reviewers and authors alike to increase clarity and quality in the application of CoP theory in medical education.

Twelve tips for implementing a community of practice for faculty development

Teaching and learning practices often fail to incorporate new concepts in the ever-evolving field of medical education. Although medical education research provides new insights into curricular development, learners' engagement, assessment methods, professional development, interprofessional education, and so forth, faculty members often struggle to modernize their teaching practices. Communities of practice (CoP) for faculty development offer an effective and sustainable approach for knowledge management and implementation of best practices. A successful CoP creates and shares knowledge in the context of a specific practice toward the development of expertise. CoPs' collaborative nature, based on the co-creation of practical solutions to daily problems, aligns well with the goals of applying best practices in health professions education and training new faculty members. In our article, we share 12 tips for implementing a community of practice for faculty development. The tips were based on a comprehensive literature review and the authors' experiences.

"Getting Out of That Siloed Mentality Early": Interprofessional Learning in a Longitudinal Placement for Early Medical Students

PURPOSE

Although descriptions of interprofessional education often focus on interactions among students from multiple professions, embedding students from 1 profession in clinical settings may also provide rich opportunities for interprofessional learning (IPL). This study examines affordances and barriers to medical students' interactions with and opportunities to learn from health care professionals while learning health systems science in clinical workplaces.

METHOD

In May 2017, 14 first-year medical students at the University of California, San Francisco participated in a semistructured interview about IPL experiences during a 17-month, weekly half-day clinical microsystem placement focused on systems improvement (SI) projects and clinical skills. Communities of practice and workplace learning frameworks informed the interview guide. The authors analyzed interview transcripts using conventional qualitative content analysis.

RESULTS

The authors found much variation among the 14 students' interprofessional interactions and experiences in 12 placement sites (7 outpatient, 4 inpatient, 1 emergency department). Factors influencing the depth of interprofessional interactions included the nature of the SI project, clinical workflow, student and staff schedules, workplace culture, and faculty coach facilitation of interprofessional interactions. Although all students endorsed the value of learning about and from diverse health care professionals, they were reluctant to engage with, or "burden," them.

CONCLUSIONS

There are significant IPL opportunities for early medical students in longitudinal placements focused on SI and clinical skills. Formal curricular activities, SI projects conducive to interprofessional interactions, and faculty development can enhance the quality of workplace-based IPL.

From Learning Psychiatry to Becoming Psychiatrists: A Qualitative Study of Co-constructive Patient Simulation

Objectives: Co-constructive patient simulation (CCPS) is a novel medical education approach that provides a participatory and emotionally supportive alternative to traditional supervision and training. CCPS can adapt iteratively and in real time to emergent vicissitudes and challenges faced by clinicians. We describe the first implementation of CCPS in psychiatry. Methods: We co-developed clinical scripts together with child and adolescent psychiatry senior fellows and professional actors with experience performing as simulated patients (SPs). We conducted the simulation sessions with interviewers blind to the content of case scenarios enacted by the SPs. Each hour-long simulation was followed by an hour-long debriefing session with all participants. We recorded and transcribed case preparation, simulation interactions, and debriefing sessions, and analyzed anonymized transcripts through qualitative analysis within a constructivist framework, aided by NVivo software. Results: Each of six CCPS sessions was attended by a median of 13 participants (range, 11-14). The first three sessions were conducted in person; the last three, which took place during the COVID-19 pandemic, via synchronized videoconferencing. Each of the sessions centered on clinically challenging and affectively charged situations informed by trainees' prior experiences. Through iterative thematic analysis we derived an alliterating "9R" model centered on three types of Reflection: (a) in action/"while doing" (Regulate, Relate, and Reason); (b) on action/"having done" (Realities, Restraints, and Relationships); and (c) for action/"will be doing" (with opportunities for Repair and Reaffirmation). Conclusions: CCPS is an experiential approach that fosters autonomous, meaningful, and individually tailored learning opportunities. CCPS and the 9R model for reflective practice can be effectively applied to psychiatry and have the potential to contribute uniquely to the educational needs of its trainees and practitioners.