The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework

The scope of health professions education requires complementary and diverse approaches to knowledge synthesis

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Strangers in a strange land: The experience of physicians undergoing remediation

INTRODUCTION

The experience of remediation in practising physicians has not been widely studied. Remediatees frequently present negative emotions, but observers can only infer the underlying reasons behind these. Understanding remediatees' perspectives may help those mandating and organising remediation to structure the process in ways that improve the experience for all concerned parties and maximise chances of a successful outcome for remediatees.

METHODS

Seventeen physicians who had undergone remediation for clinical competence concerns were interviewed via telephone. Participant data were first iteratively analysed thematically and then reanalysed using a narrative mode of analysis for each participant in order to understand the stories as wholes. Figured worlds (FW) theory was used as a lens for analysing the data for this constructivist research study.

RESULTS

Participants entering the FW of remediation perceived that their position as a 'good doctor' was threatened. Lacking experience with this world and with little available support to help them navigate it, participants used their agency to draw on various discursive threads within the FW to construct a narrative account of their remediation. In their narratives, participants tended to position themselves either as victims of regulatory bodies or as resilient individuals who could make the best of a difficult situation. In both cases, the chosen discursive threads enabled them to maintain their self-identity as 'good doctor'.

CONCLUSION

Remediation poses a threat to a physician's professional and personal identity. Focusing mainly on the educational aspect of remediation-that is, the improvement in knowledge and skills-risks missing its impact on physician identity. We need to ensure not only that we support physicians in dealing with this identity threat but that our assessment and remediation processes do not inadvertently encourage remediatees to draw on discursive threads that lead them to see themselves as victims.

Sharpening Our Tools: Conducting Medical Education Research Using Critical Theory

Issue: As medical education continues to grapple with issues of systemic racism and oppression within its institutions, educational researchers will undoubtedly turn to critical theory to help illuminate these issues. Critical theory refers both to a "school of thought" and a process of critique that reveals the dynamic forces impacting minoritized groups and individuals. Critical theory can be helpful when researchers want to examine or expose social structures for their asymmetrical power differentials, and subsequently act upon them to create change. Evidence: However, despite the repeated calls for more critical work in medical education, merely describing critical theory's school of thought has not forwarded researchers' engagement with these theories. Presently, critical analyses remain rare in medical education. One potential reason for the lack of critical analyses is that there is little guidance for how researchers might engage with their data and approach their findings. Implications: In this paper, we go beyond merely describing critical theory and demonstrate how critical theory can be used as an analytic approach to interrogate the experiences of minoritized individuals in medical education. Using three critical theories: critical race theory, feminist theory, and postcolonial theory, we provide an illustration of how researchers might approach their data using one of three critical theories. In doing so, we hope to assist researchers in better understanding the utility of critical analyses to illuminate sociohistorical forces at work within medical education.

Quality 4.0 transition framework for Tanzanian manufacturing industries

Purpose

This research aimed at developing the Quality 4.0 transition framework for Tanzanian manufacturing industries.

Design/methodology/approach

The survey method was used in this study to gather practitioners' perspectives. The approach included open-ended and closed-ended structured questionnaires to assess respondents' perceptions of Quality 4.0 awareness and manufacturers' readiness to transit to Quality 4.0. The study's objective was to adopt non-probability and purposive sampling strategies. The study focused on fifteen Tanzanian manufacturing industries. The data were analysed qualitatively and quantitatively using MAXQADA 2020 and Minitab 20 software packages, respectively.

Findings

The study demonstrated a high level of awareness of Quality 4.0 among Tanzanian manufacturing industries (i.e. 100% in Quality 4.0 traditional attributes and 53% in Quality 4.0 modern attributes). Individuals acquire knowledge in various ways, including through quality training, work experience, self-reading and Internet surfing. The result also revealed that most manufacturing industries in Tanzania use Quality 3.0 or a lower approach to manage quality. However, Tanzanian manufacturing industries are ready to embrace Quality 4.0 since practitioners are aware of the concepts and could see benefits such as customer satisfaction, product improvement, process and continuous improvement, waste reduction and decision support when using the Quality 4.0 approach. The challenges hindering Quality 4.0 adoption in Tanzania include reliable electricity, high-speed Internet and infrastructure inadequacy to support the adoption, skilled workforces familiar with Quality 4.0-enabled technologies and a financial set-up to support technology investment. Moreover, the study developed a transition framework for an organisation to transition from traditional quality approaches such as quality control, quality assurance and total quality management to Quality 4.0, a modern quality approach aligned with the fourth industrial revolution era.

Research limitations/implications

The current study solely looked at manufacturing industries, leaving other medical, service, mining and construction sectors. Furthermore, no focus was laid on the study's Quality 4.0 implementation frameworks.

Originality/value

This is probably the first Quality 4.0 transition framework for Tanzanian manufacturing industries, perhaps with other developing countries.

Lean Entrepreneurship and SME Practice in a Post COVID-19 Pandemic Era: A Conceptual Discourse from Nigeria

This study investigates lean principles among Nigerian entrepreneurs and SME managers in the operational process in the aftermath of COVID-19 pandemic in Nigeria. It offers the panacea to the challenge of social-economic shocks and their adverse effects on SMEs' business activities in Nigeria. The study adopts a conceptual approach to investigate lean entrepreneurship practice by SMEs in Nigeria. It relies on data from extant literature, using a conceptual approach to examine the social-economic effects of COVID-19 pandemic and critical environmental factors on the lean entrepreneurship practice in Nigeria. Furthermore, the study explores the influence of lean practice among SMEs and entrepreneurs in Nigeria and suggests a broad model for lean entrepreneurial practice in post-COVID-19 pandemic Nigeria. Findings highlight the broad social-economic effects of COVID-19 pandemic and other challenges such as theft, host community pressure, weak legal system, and inadequate government policy support affect lean entrepreneurship practice. These factors constitute complex operational issues that would require the adoption of a more comprehensive approach to address. It also highlights crucial factors for post-COVID-19 pandemic SMEs' operational success in Nigeria due to deficits in infrastructure and regulatory efficiency for SMEs' operations to address the various challenges of business failures in Nigeria. The study suggests a lean SME and Entrepreneurial Practice model in the post-COVID-19 pandemic era. It emphasises the need to refocus the active interest of the lean entrepreneur on critical business sustainability. The study recommends a critical review of the internal operational process among practicing entrepreneurial businesses and a re-modification of public policies system that governs the operational functions of entrepreneurial practices for reasonable and resilient post-COVID-19 pandemic entrepreneurship practices that can support the SMEs and economic growth in Nigeria.

Can stoic training develop medical student empathy and resilience? A mixed-methods study

BACKGROUND

Empathic erosion and burnout represent crises within medicine. Psychological training has been used to promote empathy and personal resilience, yet some training useful within adjacent fields remain unexplored, e.g., Stoic training. Given recent research within psychology suggesting that Stoic training increases emotional wellbeing, exploring this type of training within health professions education is important. We therefore asked: What impact would a Stoicism informed online training package have on third year medical students' resilience and empathy?

METHODS

24 third year medical students took part in 12 days of online training (SeRenE), based on Stoic philosophy, and co-developed with psychotherapists. A mixed-methods study was conducted to evaluate impact. Pre- and post-SeRenE students completed the Stoic Attitudes and Behaviours Scale (SABS), Brief Resilience Scale (BRS) and Jefferson Scale of Empathy (JSE). All students completed semi-structured interviews following training and 2 months post-SeRenE. Thematic analysis was employed to analyse qualitative data, whilst within subjects t-tests and correlational analyses were conducted on quantitative data.

RESULTS

Quantitatively, stoic ideation, resilience and empathy increased post-training, with correlational analyses suggesting resilience and empathy increase in tandem. Qualitatively, four themes were identified: 1. Negative visualisation aids emotional and practical preparedness; 2. Stoic mindfulness encourages students to think about how they think and feel; 3. Stoic reflection develops the empathic imagination; and 4. Evaluating the accessibility of SeRenE.

CONCLUSIONS

Our data lend support to the ability of Stoic-based psychological training to positively influence resilience and empathy. Although, quantitatively, results were mixed, qualitative data offers rich insight. The practice of negative visualisation, promoted by SeRenE, encourages student self-efficacy and planning, domains of resilience associated with academic success. Further, this study demonstrates a connection between Stoic practice and empathy, which manifests through development of the empathic imagination and a sense of empathic bravery.

Is reflection like soap? a critical narrative umbrella review of approaches to reflection in medical education research

Reflection is a complex concept in medical education research. No consensus exists on what reflection exactly entails; thus far, cross-comparing empirical findings has not resulted in definite evidence on how to foster reflection. The concept is as slippery as soap. This leaves the research field with the question, 'how can research approach the conceptual indeterminacy of reflection to produce knowledge?'. The authors conducted a critical narrative umbrella review of research on reflection in medical education. Forty-seven review studies on reflection research from 2000 onwards were reviewed. The authors used the foundational literature on reflection from Dewey and Schön as an analytical lens to identify and critically juxtapose common approaches in reflection research that tackle the conceptual complexity. Research on reflection must deal with the paradox that every conceptualization of reflection is either too sharp or too broad because it is entrenched in practice. The key to conceptualizing reflection lies in its use and purpose, which can be provided by in situ research of reflective practices.

Lessons learned from a pandemic: implications for a combined exercise and educational programme for medical students

BACKGROUND

The 'MED-WELL' programme is a combined exercise and educational intervention designed to promote well-being among medical students and educate students about prescribing exercise as medicine in clinical practice. Due to COVID-19 public health restrictions of social distancing the 'MED-WELL' programme was offered online instead of in-person in 2021. The aim of this study is to compare the experiences of participants in the 'MED-WELL' programme online to those that previously participated in the same programme in-person to understand the student experience and optimize programme delivery.

METHODS

Purposive sampling was used to recruit 20 participants to a qualitative study using semi-structured interviews. Ten study participants took part in the 'MED-WELL' programme when it was offered in-person, and the other ten study participants took part in the programme when it was offered online. All interviews were audio-recorded and transcribed using Microsoft Teams. A combined inductive and deductive approach was used for analysis. An inductive thematic analysis was utilized to categorize data into higher order codes, themes, and overarching themes. The theory of online learning provided the theoretical framework for a deductive approach.

RESULTS

Analysis of the data produced five overarching themes: 'student-student', 'student-teacher', 'student-content', 'student-environment', and 'effects of a pandemic'. The first four themes detail distinct types of interaction that participants had with various entities of the 'MED-WELL' programme and the effects that these interactions had on participant experiences. 'Effects of a pandemic' refers to the context of delivering the 'MED-WELL' programme online during a pandemic and how this mode of delivery influenced participants and the programme.

CONCLUSIONS

Optimizing the 'MED-WELL' programme relies on an understanding of how participants interact with different entities of the programme and are motivated to attend and engage. Participants tended to favour an in-person mode of delivery, however certain advantages of delivering the programme online were also identified. The findings from this study can be used to inform similar experiential and educational exercise interventions, and may help plan for potential future restrictions on in-person educational and exercise-based programmes.

Using Learning Theories to Develop a Veterinary Student Preparedness Toolkit for Workplace Clinical Training

Learning theories are abstract descriptions which help us make sense of educational practice. Multiple theories can inform our understanding of a single concept, in this case: veterinary workplace clinical training (WCT), which occurs just prior to students' graduation as competent veterinary surgeons. The competency movement has strongly influenced reforms in veterinary education and is considered important. In reflection of this, the term “preparedness” is operationalised here as a measure of the likelihood that the veterinary student is going to be a competent learner and participant during WCT. Preparedness itself is therefore important because it directly impacts performance. Workplace clinical training is explored through the lenses of cognitivist, social constructivist and socio-culturalist learning theories and used to inform student preparedness characteristics (“tools”) in terms of their behaviours, personal attributes, knowledge and skills, and awarenesses to optimise learning and participation. These form a new conceptual framework—the “Preparedness Toolkit.”

A practical guide to reflexivity in qualitative research: AMEE Guide No. 149

Qualitative research relies on nuanced judgements that require researcher reflexivity, yet reflexivity is often addressed superficially or overlooked completely during the research process. In this AMEE Guide, we define reflexivity as a set of continuous, collaborative, and multifaceted practices through which researchers self-consciously critique, appraise, and evaluate how their subjectivity and context influence the research processes. We frame reflexivity as a way to embrace and value researchers' subjectivity. We also describe the purposes that reflexivity can have depending on different paradigmatic choices. We then address how researchers can account for the significance of the intertwined personal, interpersonal, methodological, and contextual factors that bring research into being and offer specific strategies for communicating reflexivity in research dissemination. With the growth of qualitative research in health professions education, it is essential that qualitative researchers carefully consider their paradigmatic stance and use reflexive practices to align their decisions at all stages of their research. We hope this Guide will illuminate such a path, demonstrating how reflexivity can be used to develop and communicate rigorous qualitative research.

Learning the ropes: strategies program directors use to facilitate organizational socialization of newcomer residents, a qualitative study

BACKGROUND

Many residents experience their transitions, such as from medical student to resident, as demanding and stressful. The challenges they face are twofold: coping with changes in tasks or responsibilities and performing (new) social roles. This process of 'learning the ropes' is known as Organizational Socialization (OS). Although there is substantial literature on transitions from the perspective of residents, the voices of program directors (PDs) who facilitate and guide residents through the organizational socialization process have not yet been explored. PDs' perspectives are important, since PDs are formally responsible for Postgraduate Medical Education (PGME) and contribute, directly or indirectly, to residents' socialization process. Using the lens of OS, we explored what strategies PDs use to facilitate organizational socialization of newcomer residents.

METHODS

We conducted semi-structured interviews with 17 PDs of different specialties. We used a theory-informing inductive data analysis study design, comprising an inductive thematic analysis, a deductive interpretation of the results through the lens of OS and, subsequently, an inductive analysis to identify overarching insights.

RESULTS

We identified six strategies PDs used to facilitate organizational socialization of newcomer residents and uncovered two overarching insights. First, PDs varied in the extent to which they planned their guidance. Some PDs planned socialization as an explicit learning objective and assigned residents' tasks and responsibilities accordingly, making it an intended program outcome. However, socialization was also facilitated by social interactions in the workplace, making it an unintended program outcome. Second, PDs varied in the extent to which they adapted their strategies to the newcomer residents. Some PDs used individualized strategies tailored to individual residents' needs and skills, particularly in cases of poor performance, by broaching and discussing the issue or adjusting tasks and responsibilities. However, PDs also used workplace strategies requiring residents to adjust to the workplace without much intervention, which was often viewed as an implicit expectation.

CONCLUSIONS

PDs' used both intentional and unintentional strategies to facilitate socialization in residents, which may imply that socialization can occur irrespective of the PD's strategy. PDs' strategies varied from an individual-centered to a workplace-centered approach to socialization. Further research is needed to gain a deeper understanding of residents' perceptions of PD's efforts to facilitate their socialization process during transitions.

Junior doctors' experiences with interprofessional collaboration: Wandering the landscape

CONTEXT

The transition from medical student to junior doctor is challenging. Junior doctors need to become part of the physician community of practice (CoP), while dealing with new responsibilities, tasks and expectations. At the same time, they need to learn how to navigate the frontiers and intersections with the other communities of practice that form the Landscape of Practice (LoP). This study aims to understand how junior doctors experience interprofessional collaboration (IPC) and what elements shape these experiences considering their transition to clinical practice.

METHODS

In this multicentre qualitative study, 13 junior doctors individually drew two rich pictures of IPC experiences, one positive and one negative. A rich picture is a visual representation, a drawing of a particular situation intended to capture the complex and non-verbal elements of an experience. We used semi-structured interviews to deepen the understanding of junior doctors' depicted IPC experiences. We analysed both visual materials and interview transcripts iteratively, for which we adopted an inductive constructivist thematic analysis.

RESULTS

While transitioning into a doctor, junior doctors become foremost members of the physician CoP and shape their professional identity based on perceived values in their physician community. Interprofessional learning occurs implicitly, without input from the interprofessional team. As a result, junior doctors struggle to bridge the gap between themselves and the interprofessional team, preventing IPC learning from developing into an integrative process. This professional isolation leaves junior doctors wandering the landscape of practice without understanding roles, attitudes and expectations of others.

CONCLUSIONS

Learning IPC needs to become a collective endeavour and an explicit learning goal, based on multisource feedback to take advantage of the expertise already present in the LoP. Furthermore, junior doctors need a safe environment to embrace and reflect on the emotions aroused by interprofessional interactions, under the guidance of experienced facilitators.

Sharing the Bandwidth in Cognitively Overloaded Teams and Systems: Mechanistic Insights from a Walk on the Wild Side of Clinical Reasoning

IssuePrevious work from the diagnostic error literature has provided indirect evidence that faulty clinical reasoning may be the most frequent cause of error when attaching a diagnostic label. The precise mechanisms underlying diagnostic error are unclear and continue to be subject to considerable theory informed debate in the clinical reasoning literature. Evidence: We take a theoretical approach to merging these two worlds of literature by first zooming out using distributed cognition as a social cognitive lens (macro theory) to develop a view of the process and outcome of clinical reasoning occurring in the wild - defined as the integrated clinical workplace - the natural habitat of clinicians working within teams. We then zoom in using the novel combination of cognitive load theory and distributed cognition to provide additional theoretical insights into the potential mechanisms of error. Implications: Through the lenses of distributed cognition and cognitive load theory, we can begin to prospectively investigate how cognitive overload is represented and shared within interprofessional teams over time and space and how this influences clinical reasoning performance and leads to error. We believe that this work will help teams manage cognitive load and prevent error.

The Impact of Behavioral Anchors in the Assessment of Fellowship Applicants: Reducing Rater Biases

INTRODUCTION

No standardized evaluation tool for fellowship applicant assessment exists. Assessment tools are subject to biases and scoring tendencies which can skew scores and impact rankings. We aimed to develop and evaluate an objective assessment tool for fellowship applicants.

METHODS

We detected rater effects in our numerically scaled assessment tool (NST), which consisted of 10 domains rated from 0 to 9. We evaluated each domain, consolidated redundant categories, and removed subjective categories. For 7 remaining domains, we described each quality and developed a question with a behaviorally-anchored rating scale (BARS). Applicants were rated by 6 attendings. Ratings from the NST in 2018 were compared with the BARS from 2020 for distribution of data, skewness, and inter-rater reliability.

RESULTS

Thirty-four applicants were evaluated with the NST and 38 with the BARS. Demographics were similar between groups. The median score on the NST was 8 out of 9; scores <5 were used in less than 1% of all evaluations. Distribution of data was improved in the BARS tool. In the NST, scores from 6 of 10 domains demonstrated moderate skewness and 3 high skewness. Three of the 7 domains in the BARS showed moderate skewness and none had high skewness. Two of 10 domains in the NST vs 5 of 7 domains in the BARS achieved good inter-rater reliability.

CONCLUSION

Replacing a standard numeric scale with a BARS normalized the distribution of data, reduced skewness, and enhanced inter-rater reliability in our evaluation tool. This provides some validity evidence for improved applicant assessment and ranking.

Reframing professional identity through navigating tensions during residency: A qualitative study

INTRODUCTION

Professional identity formation (PIF) is the internalization of characteristics, values, and norms of the medical profession. An individual's identity formation has both psychological and sociological influences. Social psychology may be useful to explore the interactions between the psychological and sociological aspects of PIF. In this study, we explored how resident physicians navigated tensions between professional ideals and the reality of medical practice to characterize PIF during residency training.

METHODS

Using constructivist grounded theory, the authors conducted 23 semi-structured interviews with internal medicine residents. Interview transcripts were processed through open coding and analytic memo writing. During data gathering and analysis, the authors utilized Social Cognitive Theory, specifically the bidirectional influence between person, behavior, and context, to analyze relationships among themes. Theoretical insights were refined through group discussion and constant comparison with newly collected data.

RESULTS

Residents described tensions experienced during residency between pre-existing ideals of "a good doctor" and the realities of medical practice, often challenging residents to reframe their ideals. The authors provide evidence for the presence of dynamic, bidirectional influences between identity (person), behavior, and environment (context), and demonstrate how PIF is informed by a complex interplay between these elements. The authors present two examples to demonstrate how residents reframed their ideals during residency training.

DISCUSSION

The complex bidirectional influences between person, behavior, and context, informed by SCT, helps illuminate the process of PIF in residency training. This study highlights the effects of the context of residency training on the development of residents' professional identities.

Conducting qualitative research through time: how might theory be useful in longitudinal qualitative research?

This paper explores the use of theory in longitudinal qualitative research, an approach to research which explores lived experiences as they unfold. The authors illustrate how the complexity of conducting qualitative research through time drives an understanding and use of theory that differs from other research approaches. Longitudinal qualitative research considers time as fluid, subjective, and unbounded-in contrast to the more common taken-for-granted understanding of time as fixed, objective, and linear. Furthermore, longitudinal qualitative research is predicated on a premise of trust in the context of enduring research relationships. Therefore, while subject-matter theories used to investigate topics of interest to health professions educators may be useful frameworks for other types of research, longitudinal qualitative research needs theories that accommodate the myriad of changes in lived experiences through time. The authors share their decade-long, longitudinal qualitative research story, highlighting their decision points and insights. In doing so, they foreground issues such as time as fluid as an important contribution to health professions education literature.

Role Identity, Dissonance, and Distress among Paramedics

Role identity theory describes the purpose and meaning in life that comes, in part, from occupying social roles. While robustly linked to health and wellbeing, this may become unideal when an individual is unable to fulfill the perceived requirements of an especially salient role in the manner that they believe they should. Amid high rates of mental illness among public safety personnel, we interviewed a purposely selected sample of 21 paramedics from a single service in Ontario, Canada, to explore incongruence between an espoused and able-to-enact paramedic role identity. Situated in an interpretivist epistemology and using successive rounds of thematic analysis, we developed a framework for role identity dissonance wherein chronic, identity-relevant disruptive events cause emotional and psychological distress. While some participants were able to recalibrate their sense of self and understanding of the role, for others, this dissonance was irreconcilable, contributing to disability and lost time from work. In addition to contributing a novel perspective on paramedic mental health and wellbeing, our work also offers a modest contribution to the theory in using the paramedic context as an example to consider identity disruption through chronic workplace stress.

"Must you make an app?" A qualitative exploration of socio-technical challenges and opportunities for designing digital maternal and child health solutions in Soweto, South Africa

Participatory and digital health approaches have the potential to create solutions to health issues and related inequalities. A project called Co-Designing Community-based ICTs Interventions for Maternal and Child Health in South Africa (CoMaCH) is exploring such solutions in four different sites across South Africa. The present study captures initial qualitative research that was carried out in one of the urban research sites in Soweto. The aim was twofold: 1) to develop a situation analysis of existing services and the practices and preferences of intended end-users, and 2) to explore barriers and facilitators to utilising digital health for community-based solutions to maternal and child health from multiple perspectives. Semi-structured interviews were conducted with 28 participants, including mothers, other caregivers and community health workers. Four themes were developed using a framework method approach to thematic analysis: coping as a parent is a priority; existing services and initiatives lack consistency, coverage and effective communication; the promise of technology is limited by cost, accessibility and crime; and, information is key but difficult to navigate. Solutions proposed by participants included various digital-based and non-digital channels for accessing reliable health information or education; community engagement events and social support; and, community organisations and initiatives such as saving schemes or community gardens. This initial qualitative study informs later co-design phases, and raises ethical and practical questions about participatory intervention development, including the flexibility of researcher-driven endeavours to accommodate community views, and the limits of digital health solutions vis-à-vis material needs and structural barriers to health and wellbeing.

Behavioral and Psychological Aspects of the Physician Experience with Deimplementation

INTRODUCTION

Deimplementation, or the structured elimination of non-evidence-based practices, faces challenges distinct from those associated with implementation efforts. These barriers may be related to intrinsic psychological factors, as perceptions and emotions surrounding the discontinuation of established practices appear to differ from those associated with practice adoption. This study aims to explore barriers and facilitators experienced by pediatric clinicians engaging in deimplementation projects.

METHODS

We used behavioral economics concepts to inform our qualitative study design following a theory-informed inductive approach. We conducted semistructured interviews with participants from two national quality improvement collaboratives where the primary outcomes were deimplementation measures. Using purposeful sampling, we recruited project leaders at institutions in the top and bottom quartiles from within each collaborative. Finally, we conducted a thematic analysis using a combination of inductive and deductive coding.

RESULTS

In total, we interviewed participants from 12 high-performing sites and 7 low-performing sites. Participants identified nine concepts associated with successful deimplementation practice and three psychological barriers that impacted behavior change: (1) loss, (2) fear, and (3) action bias. Participants further identified four overarching strategies for mitigating the identified psychological barriers, including (1) making allowance for nonconformism; (2) permission to change; (3) normalizing; and (4) reframing.

CONCLUSION

There is potential for more effective deimplementation through the proactive incorporation of an awareness of specific psychological barriers of loss, fear, and action bias, as well as specific mitigation strategies to address the psychocognitive experience.

Qualitative ego networks in health professions education: Capturing the self in relation to others

INTRODUCTION

Our very sense of self emerges through interactions with others. As part of this State of the Science series on Self, Society, and Situation, we introduce a qualitative ego network research approach. This research approach offers insights into the self's (the ego's) interpretation of and relation to named others in the social network in question.

PURPOSE

Visual mapping of participants' social networks is gaining traction, yet this research approach has received no focused attention in the health professions education (HPE) literature. A qualitative ego network approach is a compelling research approach because it uniquely maps participants' perceptions of the complex social world they are embedded in. Although many methodologies can explore participants' social world, ego networks can enhance expression of tacit knowledge of one's social environment and encourage reflection. This approach, combined with other qualitative data, can also reveal hidden relational data that the researcher may not observe or consider. To demonstrate its value as a visual methodology, we will showcase two examples of qualitative ego network studies. We then balance the paper with some critical reflections of this research approach.

CONCLUSIONS

A qualitative ego network approach holds potential for deepening understanding of the self in relation to society and situation in future HPE research. We look forward to intentional, impactful and invigorated research using a qualitative ego network approach as we tackle unknowns about how self and society in specific HPE situations interact.

Gender Equity in Disability Sport: A Rapid Scoping Review

Aim: A scoping review was conducted to map the literature related to gender equity in disability sport. Design: Six databases relevant to the sport sciences were searched, yielding an initial 1,543 records; after two phases of screening and data extraction, 61 records were selected for synthesis. Descriptive statistics were generated on information related to the record contexts, approaches, and results. Qualitative descriptive analyses were used to group data inductively into themes in line with addressing the research question. Results: Most records examined the experiences, participation, and representation of adults in elite contexts. Insights across records pointed to gender inequities in participation and experience, often influenced by the intersection of ableist and masculinity notions. Limited research also pointed to strategies that can contribute to advancing gender equity. Conclusions: Implications were discussed to advance understandings of disability sport and enhance participation across levels (e.g., coaching, athletic) and contexts (e.g., elite/Paralympic, recreational).

A Smartphone App (AnSim) With Various Types and Forms of Messages Using the Transtheoretical Model for Cardiac Rehabilitation in Patients With Coronary Artery Disease: Development and Usability Study

Background

Despite strong evidence of clinical benefit, cardiac rehabilitation (CR) programs are currently underutilized and smartphone-based CR strategies are thought to address this unmet need. However, data regarding the detailed process of development are scarce.

Objective

This study focused on the development of a smartphone-based, patient-specific, messaging app for patients who have undergone percutaneous coronary intervention (PCI).

Methods

The AnSim app was developed in collaboration with a multidisciplinary team that included cardiologists, psychiatrists, nurses, pharmacists, nutritionists, and rehabilitation doctors and therapists. First, a focus group interview was conducted, and the narratives of the patients were analyzed to identify their needs and preferences. Based on the results, health care experts and clinicians drafted messages into 5 categories: (1) general information regarding cardiovascular health and medications, (2) nutrition, (3) physical activity, (4) destressing, and (5) smoking cessation. In each category, 90 messages were developed according to 3 simplified steps of the transtheoretical model of behavioral change: (1) precontemplation, (2) contemplation and preparation, and (3) action and maintenance. After an internal review and feedback from potential users, a bank of 450 messages was developed.

Results

The focus interview was conducted with 8 patients with PCI within 1 year, and 450 messages, including various forms of multimedia, were developed based on the transtheoretical model of behavioral change in each category. Positive feedback was obtained from the potential users (n=458). The mean Likert scale score was 3.95 (SD 0.39) and 3.91 (SD 0.39) for readability and usefulness, respectively, and several messages were refined based on the feedback. Finally, the patient-specific message delivery system was developed according to the baseline characteristics and stages of behavioral change in each participant.

Conclusions

We developed an app (AnSim), which includes a bank of 450 patient-specific messages, that provides various medical information and CR programs regarding coronary heart disease. The detailed process of multidisciplinary collaboration over the course of the study provides a scientific basis for various medical professionals planning smartphone-based clinical research.

Medical Student Experience and Outcomes, as Well as Preceptor Experience, with Rapid Conversion of a Preclinical Medical School Course to a Remote-Based Learning Format in the Setting of the COVID-19 Pandemic

OBJECTIVES

To assess student outcomes and experiences, as well as preceptor experiences, after emergently converting a preclinical medical school renal course to a remote setting during the COVID-19 pandemic.

METHODS

First-year medical student examination scores and responses to Likert-scale questions on end-of-course evaluations from the 2018-2019 (traditional) and 2019-2020 (remote) academic years were compared. Free-text responses from students and preceptors were analyzed using a qualitative summative approach to extract major themes in perceptions of remote learning.

RESULTS

Mean student scores on course examinations did not significantly differ between the traditional and remote settings (p = 0.23 and 0.84 respectively). Quantitative analysis of student evaluations revealed no significant difference across all items in mean Likert-scale responses. Student and preceptor free-text responses identified course leader engagement and responsiveness as essential to the success of remote-based learning. Optimal group size and online etiquette are areas that require attention.

CONCLUSIONS

Despite rapid conversion of a preclinical medical school renal course to a remote-based format in the setting of the COVID-19 pandemic, student scores and evaluations remain positive and largely unchanged.

Theory in quality improvement and patient safety education: A scoping review

INTRODUCTION

Theory plays an important role in education programming and research. However, its use in quality improvement and patient safety education has yet to be fully characterized. The authors undertook a scoping review to examine the use of theory in quality improvement and patient safety education.

METHODS

Eligible articles used theory to inform the design or study of a quality improvement or patient safety curriculum. The authors followed scoping review methodology and searched articles referenced in 20 systematic reviews of quality improvement and patient safety education, or articles citing one of these reviews, and hand searched eligible article references. Data analysis involved descriptive and interpretive summaries of theories used and the perspectives the theories offered.

RESULTS

Eligibility criteria were met by 28 articles, and 102 articles made superficial mention of theory. Eligible articles varied in professional group, learning stage and journal type. Theories fell into two broad categories: learning theories (n = 20) and social science theories (n = 11). Theory was used in the design (n = 12) or study (n = 17) of quality improvement and patient safety education. The range of theories shows the opportunity afforded by using more than one type of theory.

DISCUSSION

Theory can guide decisions regarding quality improvement and patient safety education practices or play a role in selecting a methodology or lens through which to study educational processes and outcomes. Educators and researchers should make deliberate choices around the use of theory that relates to aspects of an educational program that they seek to illuminate.

Experiences of Wearable Technology by Persons with Knee Osteoarthritis Participating in a Physical Activity Counseling Intervention: Qualitative Study Using a Relational Ethics Lens

Background

Current evidence indicates physical activity wearables could support persons with knee osteoarthritis (OA) to be more physically active. However, recent evidence also identifies some persons with arthritis experience guilt or worry while using a wearable if they are not as active as they feel they should be. Questions remain around how persons with knee OA experience benefits or downsides using a wearable in their everyday lives. Better understanding is needed if wearables are to be incorporated in arthritis self-management in ethically aware ways.

Objective

Using an ethics lens, we aimed to describe a range of experiences from persons with knee OA who used a wearable during a physical activity counseling intervention study.

Methods

This is a secondary analysis of qualitative interviews nested within a randomized controlled trial. Guided by phenomenography, we explored the experiences of persons with knee OA following participation in a physical activity counseling intervention that involved using a Fitbit Flex and biweekly phone calls with a study physiotherapist (PT) in an 8-week period. Benefits or downsides experienced in participants’ relationships with themselves or the study PT when using the wearable were identified using a relational ethics lens.

Results

Interviews with 21 participants (12 females and 9 males) aged 40 to 82 years were analyzed. Education levels ranged from high school graduates (4/21, 19%) to bachelor’s degrees or above (11/21, 52%). We identified 3 categories of description: (1) participants experienced their wearable as a motivating or nagging influence to be more active, depending on how freely they were able to make autonomous choices about physical activity in their everyday lives; (2) some participants felt a sense of accomplishment from seeing progress in their wearable data, which fueled their motivation; (3) for some participants, sharing wearable data helped to build mutual trust in their relationship with the study PT. However, they also expressed there was potential for sharing wearable data to undermine this trust, particularly if this data was inaccurate.

Conclusions

Findings provide an early glimpse into positive and negative emotional impacts of using a wearable that can be experienced by participants with knee OA when participating in a randomized controlled trial to support physical activity. To our knowledge, this is the first qualitative study that uses a relational ethics lens to explore how persons with arthritis experienced changes in their relationship with a health professional when using a wearable during research participation.

Coproducing clinical curricula in undergraduate medical education: Student and faculty experiences in longitudinal integrated clerkships

PURPOSE

Educational coproduction, in which learners partner with educators to create and improve their educational experiences, can facilitate student-centered medical education. Empirical descriptions of best practices for involving students in clinical curricular coproduction are needed. We aimed to understand faculty and student perspectives on methods, perceived benefits, and common barriers and solutions to clinical curricular coproduction.

METHODS

We conducted an international mixed-methods study of clinical curricular coproduction in undergraduate medical education and longitudinal integrated clerkships specifically. Faculty and students identified through an international listserv received an electronic survey to identify methods, benefits, and challenges of clinical curricular coproduction. We conducted semi-structured interviews with a subset of survey participants. We present descriptive statistics for survey data and themes derived from inductive qualitative analysis.

RESULTS

Two hundred forty-seven individuals (104 faculty; 143 students) representing 52 medical schools in eight countries completed the survey. Methods for clinical curricular coproduction ranged from informal, low-intensity learner involvement (e.g. verbal feedback) to formal, high-intensity learner involvement (e.g. committee membership). Perceived benefits included improvements in student-faculty relationships, program culture and design, and student development. Structural issues (e.g. scheduling) were the most common perceived barriers.

CONCLUSIONS

Clinical curricular coproduction among faculty and students is perceived to enhance collaboration, enable curriculum change, and support students' professional development. Our study offers empirical guidance for involving students as partners in clinical curricular coproduction.

Training for Professional Uncertainty: Socialization of Medical Students Through the Residency Application Process

PURPOSE

Uncertainty in medical decision making is a well-described phenomenon, and numerous scholars have acknowledged and illustrated the process of training medical students to grapple with this aspect of medical practice. While clinical uncertainty has been defined previously, medical trainees face additional forms of uncertainty beyond the clinical setting that have not, as yet, been investigated empirically. One area in which uncertainty can manifest outside of the clinical setting is during professional development. Medical students face substantial stress and ambiguity throughout their training, with the residency application period representing a culmination of these pressures. Here, the authors examined medical students' experiences during the residency application period and used these findings to define training for professional uncertainty.

METHOD

In 2018-2019, 6 focus groups of fourth-year medical students were conducted exploring students' experiences during the residency application period, including but not limited to Step 2 Clinical Knowledge, away rotations, and securing letters of recommendation. The authors then used constructivist, phenomenological methods to analyze participant responses.

RESULTS

Students frequently discussed challenges they faced during the residency application period. From these conversations, 2 themes were identified: (1) professional uncertainty related to career-based advice, which resulted from mixed messaging and inadequate information, and (2) professional uncertainty related to competing responsibilities, which students experienced when determining how to allocate a limited amount of time to multiple conflicting forces.

CONCLUSIONS

These results were used to define a novel concept-training for professional uncertainty. By navigating the residency application process, students learned to face various facets of professional uncertainty that they will continue to face throughout their careers. Since uncertainty can have many negative effects, including declining performance and burnout, defining professional uncertainty and training students to grapple with it is necessary to maximize their success throughout their careers.

Oral health issues of young adults with severe intellectual and developmental disabilities and caregiver burdens: a qualitative study

Background

Oral health maintenance is difficult to be achieved alone by patients with special needs and insufficient self-care skills. This study aims to investigate how the oral health issues of young adults with severe intellectual and developmental disabilities (IDD) affect caregiver burdens.

Methods

A qualitative research method was employed with semi-structured interviews conducted with 14 maternal caregivers of patients with severe IDD. Eleven young adults had neurofunctional disorders and three had autism spectrum disorders. All recorded data were transcribed verbatim and subjected to thematic analysis.

Results

Three themes emerged from the main agenda: predisposing oral dysfunction, home care challenges, and professional treatment barriers. The severity of the disabilities had an impact on oral disease risks that increased as patients aged. Participants indicated that, among the daily living activities of their patients, toothbrushing was a particular hardship due to their dysphagia and behavioral issues. Factors impacting on dental treatment indicated by caregivers included social, emotional, and financial circumstances.

Conclusions

Dysphagia and behavioral issues of adult patients with severe IDD contributed to caregiver burdens in the dental care of the patients. Caregiver burdens and barriers to treatment were mutual factors hindering adequate interventions in dealing with dental problems of the patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01896-3.

Navigating landscapes of practice: A longitudinal qualitative study of physicians in medical education

INTRODUCTION

Despite its widespread application in medical education, belonging to a single community of practice does not reflect the overall experience of physician-educators. Knowing how physician-educators find their way among different communities of practice (ie their landscape of practice) has implications for professional development but the limited description in the literature. In this longitudinal qualitative research, we explored how physicians who pursue graduate degrees in medical education navigate their landscape of practice.

METHODS

11/29 physicians in one cohort of a masters in medical education programme were interviewed annually from 2016 (programme start) to 2020 (2 years post-graduation). We iteratively collected and analysed data, creating inductive codes and categorising coded data by mode of identification (engagement, imagination, alignment) and time. We organised narratives into time-ordered data matrices so that final analysis wove together mode, time and participant.

RESULTS

All participants consistently spoke of navigating their landscape of practice, which included the community created in the graduate programme; but that single community 'doesn't define the journey itself'. They shifted engagement from teaching individual learners to translating what they learned in the graduate programme to develop educational projects and produce scholarship. They shifted the imagination from relying on internal and external assessments to experience-inspired versions of their future self. And they shifted alignment from belonging to the graduate programme's community of practice, then belonging to different communities in their landscape of practice and ultimately focussing on communities that mattered most to them.

DISCUSSION

Physicians in a graduate programme in medical education navigated their dynamic landscape of practice by shifting how they engaged in medical education, as well as what they imagined and who they aligned with as physician-educators. Our work offers novel insights into how knowledgeability emerges through time as overlapping modes of identification.

New ways of seeing: supplementing existing competency framework development guidelines with systems thinking

Competency frameworks provide a link between professional practice, education, training, and assessment. They support and inform downstream processes such as curriculum design, assessment, accreditation and professional accountability. However, existing guidelines are limited in accounting for the complexities of professional practice potentially undermining utility of such guidelines and validity of outcomes. This necessitates additional ways of "seeing" situated and context-specific practice. We highlight what a conceptual framework informed by systems thinking can offer when developing competency frameworks. Mirroring shifts towards systems thinking in program evaluation and quality improvement, we suggest that similar approaches that identify and make use of the role and influence of system features and contexts can provide ways of augmenting existing guidelines when developing competency frameworks. We framed a systems thinking approach in two ways. First using an adaptation of Ecological Systems Theory which offers a realist perspective of the person and environment, and the evolving interaction between the two. Second, by employing complexity thinking, which obligates attention to the relationships and influences of features within the system, we can explore the multiple complex, unique, and context-embedded problems that exist within and have stake in real-world practice settings. The ability to represent clinical practice when developing competency frameworks can be improved when features that may be relevant, including their potential interactions, are identified and understood. A conceptual framework informed by systems thinking makes visible features of a practice in context that may otherwise be overlooked when developing competency frameworks using existing guidelines.

Thoughts that breathe, and words that burn: poetic inquiry within health professions education

Qualitative inquiry is increasingly popular in health professions education, and there has been a move to solidify processes of analysis to demystify the practice and increase rigour. Whilst important, being bound too heavily by methodological processes potentially represses the imaginative creativity of qualitative expression and interpretation-traditional cornerstones of the approach. Rigid adherence to analytic steps risks leaving no time or space for moments of 'wonder' or emotional responses which facilitate rich engagement. Poetic inquiry, defined as research which uses poetry 'as, in, [or] for inquiry', offers ways to encourage creativity and deep engagement with qualitative data within health professions education. Poetic inquiry attends carefully to participant language, can deepen researcher reflexivity, may increase the emotive impact of research, and promotes an efficiency of qualitative expression through the use of 'razor sharp' language. This A Qualitative Space paper introduces the approach by outlining how it may be applied to inquiry within health professions education. Approaches to engaging with poetic inquiry are discussed and illustrated using examples from the field's scholarship. Finally, recommendations for interested researchers on how to engage with poetic inquiry are made, including suggestions as to how to poetize existing qualitative research practices.

Threshold concepts in group-based mentoring and implications for faculty development: A qualitative analysis

INTRODUCTION

The literature on faculty development programs for mentors is scarce. This study examines mentors' experiences and challenges, with the aim of identifying threshold concepts in mentoring. It also discusses the implications for the faculty development of mentors.

METHODS

Semi-structured interviews solicited personal narratives and reflections on mentors' lived experiences. Data analysis was guided by the threshold concepts framework allowing for the identification of significant and transformative shifts in perspectives.

RESULTS

We interviewed 22 mentors from two Norwegian and one Canadian medical school with group-based mentoring programs. The mentoring experience involved four significant threshold concepts: focusing on students' needs; the importance of creating a trusting learning space; seeing oneself through the eyes of students; and aligning mentor and physician identities.

CONCLUSION

Taking on a mentor role can provoke personal and professional dilemmas while also sparking growth. The trajectories of developing as a mentor and as a professional physician may be seen to mutually validate, mirror and reinforce each other. Faculty development programs designed specifically for mentors should aim to stimulate reflection on previous learning experiences and strive for a successful alignment of the distinct pedagogical and clinical content knowledge required to fulfill various professional roles.

COVID-19 Pandemic Impact on Substance Misuse: A Social Media Listening, Mixed Method Analysis

The restrictive measures adopted during the COVID-19 pandemic modified some previously consolidated drug use patterns. A focus on social networks allowed drug users to discuss, share opinions and provide advice during a worldwide emergency context. In order to explore COVID-19-related implications on drug trends/behaviour and on most popular psychotropic substances debated, the focus here was on the constantly updated, very popular, Reddit social platform’s posts and comments. A quantitative and qualitative analysis of r/Drugs and related subreddits, using a social media listening netnographic approach, was carried out. The post/comments analysed covered the time-frame December 2019–May 2020. Between December 2019 and May 2020, the number of whole r/Drugs subreddit members increased from 619,563 to 676,581 members, respectively, thus increasing by 9.2% by the end of the data collection. Both the top-level r/Drugs subreddit and 92 related subreddits were quantitatively analysed, with posts/comments related to 12 drug categories. The drugs most frequently commented on included cannabinoids, psychedelics, opiates/opioids, alcohol, stimulants and prescribed medications. The qualitative analysis was carried out focussing on four subreddits, relating to some 1685 posts and 3263 comments. Four main themes of discussion (e.g., lockdown-associated immunity and drug intake issues; drug-related behaviour/after-quarantine plans’ issues; lockdown-related psychopathological issues; and peer-to-peer advice at the time of COVID-19) and four categories of Redditors (e.g., those continuing the use of drugs despite the pandemic; the “couch epidemiologists”; the conspirationists/pseudo-science influencers; and the recovery-focused users) were tentatively identified here. A mixed-methods, social network-based analysis provided a range of valuable information on Redditors’ drug use/behaviour during the first phase of the COVID-19 pandemic. Further studies should be carried out focusing on other social networks as well as later phases of the pandemic.

Research environment and resources to support pediatric emergency medicine fellow research

BACKGROUND

There is a need for pediatric emergency medicine (PEM) researchers, but the current state of PEM fellow research training is not well described. We sought to (1) describe resources and gaps in PEM fellowship research training and (2) assess agreement between fellow and program director (PD) perceptions of these in fellow research experience.

METHODS

Surveys were distributed electronically to U.S. PEM fellows and PDs from March to April 2020. Fellows and PDs were queried on program research infrastructure and current gaps in fellow research experience. For programs that had at least one fellow and PD response, each fellow response was compared to their PD's corresponding response (reference standard). For each binary survey item, we determined the percent of responses with agreement between the fellow and PD.

RESULTS

Of 79 fellowship programs, 70 (89%) were represented with at least one response, including responses from 59 PDs (75%) and 218 fellows (39% of all fellows, representing 80% of programs). Fellows and PDs identified mentorship and faculty engagement as the most important needs for successful fellowship research; for every one fellow there was a median of 0.8 potential faculty mentors in the division. Twenty percent of fellows were not satisfied with mentorship opportunities. There was no association between fellow career research intent (high, defined as ≥20% dedicated time, or low) with current year of training (p = 0.88), program size (p = 0.67), and area of research focus (p = 0.40). Fellows were often unaware of research being performed by division faculty.

CONCLUSION

PEM fellows were not consistently aware of resources available to support research training. To better support PEM fellows' research training, many programs may need to expand mentorship and increase fellows' awareness of local and external resources and opportunities.

Success and limiting factors in health service innovation: a theory-generating mixed methods evaluation of UK projects

OBJECTIVES

To explore and explain success and limiting factors in UK health service innovation.

DESIGN

Mixed methods evaluation of a series of health service innovations involving a survey and interviews, with theory-generating analysis.

SETTING

The research explored innovations supported by one of the UK's Academic Health Science Networks which provides small grants, awards and structural support to health service innovators including clinical academics, health and social care professionals and third-sector organisations.

PARTICIPANTS

All recipients of funding or support 2014-2018 were invited to participate. We analysed survey responses relating to 56 innovation projects.

RESULTS

Responses were used to conceptualise success along two axes: value creation for the intended beneficiaries and expansion beyond its original pilot. An analysis of variance between categories of success indicated that participation, motivation and evaluation were critical to value generation; organisational, educational and administrative support were critical to expansion; and leadership and collaborative expertise were critical to both value creation and expansion. Additional limiting factors derived from qualitative responses included difficulties navigating the boundaries and intersections between organisations, professions, sectors and cultures; a lack of support for innovation beyond the start-up phase; a lack of protected time; and staff burn-out and turnover.

CONCLUSIONS

A nested hierarchy of innovation needs has been derived via an analysis of these factors, providing targeted suggestions to enhance the success of future innovations.

Inside-out: normalising practice-based IPE

Practice-based interprofessional education (IPE), a key feature in developing a collaboration-ready workforce, is poorly integrated in healthcare curriculums. This study aimed to synthesise educator perspectives on implementing practice-based IPE and develop recommendations to inform sustainable practice-based IPE. An ethnographic case study was carried out at a school of allied health. Data collection involved six observations, 11 interviews and a review of eight documents. Reflexive thematic analysis, informed by Normalisation Process Theory, established two key themes. First, we found that strategic planning is needed, with a coherent implementation agenda and planned reflection on activities. Second, building partnerships with placement partners was identified as essential. This can be achieved by supporting and championing practice-based IPE activities developed by placement sites and establishing how university and clinical educators can work collaboratively to deliver sustainable practice-based IPE. These conditions create a favourable environment for normalising practice-based IPE in healthcare curriculums, benefitting students, patients, and the overall healthcare service.

Qualitative exploration of the medical learner's journey into correctional health care at an academic medical center and its implications for medical education

Correctional systems in several U.S. states have entered into partnerships with academic medical centers (AMCs) to provide healthcare for persons who are incarcerated. One AMC specializing in the care of incarcerated patients is the University of Texas Medical Branch at Galveston (UTMB), which hosts the only dedicated prison hospital in the U.S. and supplies 80% of the medical care for the entire Texas Department of Criminal Justice (TDCJ). Nearly all medical students and residents at UTMB take part in the care of the incarcerated. This research, through qualitative exploration using focus group discussions, sets out to characterize the correctional care learning environment medical trainees enter. Participants outlined an institutional culture of low prioritization and neglect that dominated the learning environment in the prison hospital, resulting in treatment of the incarcerated as second-class patients. Medical learners pointed to delays in care, both within the prison hospital and within the TDCJ system, where diagnostic, laboratory, and medical procedures were delivered to incarcerated patients at a lower priority compared to free-world patients. Medical learners elaborated further on ethical issues that included the moral judgment of those who are incarcerated, bias in clinical decision making, and concerns for patient autonomy. Medical learners were left to grapple with complex challenges like the problem of dual loyalties without opportunities to critically reflect upon what they experienced. This study finds that, without specific vulnerable populations training for both trainees and correctional care faculty to address these institutional dynamics, AMCs risk replicating a system of exploitation and neglect of incarcerated patients and thereby exacerbating health inequities.

Supporting Clinician-Scientist Development in Child Psychiatry: A Four-Domain Model for Individual or Programmatic Self-Reflection

Background: The Albert J. Solnit Integrated Training Program (AJSP) is a novel educational initiative designed to prepare physician-scientists for independent careers in the investigation and treatment of childhood psychiatric disorders. Methods: We conducted a qualitative study to explore the impact and active components of the AJSP through hour-long individual interviews of its enrollees and graduates. We were specifically interested in identifying individual or programmatic traits for success that could be replicated elsewhere. As components of our theoretical framework, we used sources on Strength, Weakness, Opportunity, and Threat (SWOT) Analysis as applied to healthcare, and on mentorship and career development as pertaining to child and adolescent psychiatry (CAP). Results: Thirty-four individuals matriculated into the AJSP between 2004 and 2020, 33 (97%) of whom participated. Through iterative thematic analysis, we developed a model consisting of quadrants resulting from the intersection of a developmental perspective (spanning professional or personal spheres) and a reflective direction (with outward- or inward-facing vantage points). The model can be of practical utility through putative questions that trainees/program leaders could ask themselves by using the four domains as points of departure: (I) Individual: "Is becoming a clinician-scientist right for me?"/"What traits are we looking for in prospective applicants?"; (II) Program: "Is this the right program for me?"/"What is the right balance between structure and freedom for trainees to thrive in?"; (III) Mentorship: "What is the right number and constellation of mentors for me?"/"How can we optimize our experience and backgrounds toward the benefit of our trainees?"; and (IV) Charting Course: "Who do I want to become?"/"How can we help our charges embrace, find, or reconnect with their true vocation?" Conclusion: Our analytic approach can help identify, refine, and replicate programs that are urgently needed to increase the workforce of clinician-scientists dedicated to improving the well-being and mental health of children and families. The model we describe can be fruitfully applied to the self-reflection by individuals or program leaders. Although based on a single program with very specific goals, the model could also be applied to other training initiatives within psychiatry-and beyond.

The myth of ivory tower versus practice-oriented research: A systematic review of randomised studies in medical education

CONTEXT

A long-standing myth in medical education research is a divide between two different poles: research aiming to advance theory with little focus on practical applications ('ivory tower' research) and practically oriented research aiming to serve educators and decision-makers with little focus on advancing theory ('in-the-trenches' practice). We explored this myth in a sample of randomised medical education studies using Stokes' four-quadrant framework for the classification of research perspective.

METHODS

We searched MEDLINE, Embase, CINAHL, PsychINFO, ERIC, Web of Science and Scopus for studies in medical education using a randomised design that were published between 1 January 2018 and 31 December 2018. We used Stokes' four-quadrant framework to categorise the studies according to their use of theory, concepts and their justification for practical use. We compared medical education research published in medical education journals and clinical journals.

RESULTS

A total of 150 randomised studies were included in the analysis. The largest segment of studies (46.7%) was categorised as use-inspired basic research (Pasteur's Quadrant), closely followed by pure applied research (40.7%, Edison's Quadrant). Only a few studies were categorised as aiming to advance knowledge with no thought for practical educational application (2.0%, Bohr's Quadrant). The proportion of studies that included educational concepts and theory differed according to publication in clinical journals or medical education journals: 40.5% vs 71.8%, respectively, P < .001. There were no differences between journals with regard to the proportion of studies that included a practical educational or clinical rationale (P = .99).

CONCLUSION

In a large sample of studies using randomised designs, we found no evidence to support the myth that medical education research divides between two singular poles represented by 'ivory tower research' and 'in-the-trenches practice'. We did confirm prevailing assumptions regarding an emphasis on non-theoretical medical education research in clinical journals.

Shaping our worldviews: a conversation about and of theory

This paper introduces a new column in the Journal for the exploration of and reflection on the roles and articulations of theory in the health professions education sciences. This introduction provides initial orientation to concepts such as theory as worldview, theory linked to empiricism and paradigm, and theory and reflexivity. The authors invite scholars to submit papers that explore the role of theory in HPE scholarship, that propose new and adapted theoretical positions, and that critique the many theories that might be brought to bear to address questions in the field.

Learning Echocardiography in the Workplace: A Cognitive Load Perspective

PURPOSE

Although workplace learning environments provide authentic tasks to promote learning, elements of clinical settings may distract trainees and impede learning. The characteristics of workplace learning environments that require optimization are ill-defined. Applying principles of cognitive load theory (CLT) to optimize learning environments by managing intrinsic load (complexity of the task matched to learner knowledge and skill), minimizing extraneous load (any aspect that is not part of task completion), and increasing germane load (processing for storage in long-term memory) could be advantageous. The authors explored trainee perceptions of characteristics that helped or impaired learning from a cognitive load perspective. Echocardiography interpretation was used as a model.

METHOD

The authors conducted semistructured interviews between December 2018 and March 2019 with a purposeful sample of 10 cardiology trainees at the University of California, San Francisco, School of Medicine until thematic sufficiency was achieved. Participants represented a range of training levels (3 fourth-year trainees, 2 fifth-year trainees, 3 sixth-year trainees, and 2 advanced echocardiography fellows) and career aspirations (4 desired careers in imaging). Two independent coders analyzed interview transcripts using template analysis. Codes were mapped to CLT subcomponents.

RESULTS

Trainees selected their own echocardiograms to interpret; if trainees' skill levels and the complexity of the selected echocardiograms were mismatched, excess intrinsic load could result. Needing to look up information essential for task completion, interruptions, reporting software, and time pressures were characteristics that contributed to extraneous load. Characteristics that related to increasing germane load included the shared physical space (facilitating reading echocardiograms with attendings and just-in-time guidance from near peers) and the availability of final reports to obtain feedback independent of teachers.

CONCLUSIONS

As interpreted from a cognitive load perspective, findings highlight characteristics of workplace learning environments that could be optimized to improve learning. The findings have direct application to redesigning these learning environments.

Considerations on Conducting Research on Wellness in the Context of the Learning Environment

The learning environment (LE) provides a context for many educational phenomena, of which wellness and burnout are particularly important. The LE can be thought of as consisting of a psychosocial dimension of personal, social, and organizational factors and a sociomaterial dimension that consists of spatial and technical factors. The interplay between elements of the LE and wellness of the participants is complex and only partially understood, requiring further research. Using this multidimensional model to describe and to plan to deliberately modify the learning environment can foster more rigorous and meaningful research evidence about the interaction of wellness and the LE. This article highlights four key considerations that scholars of wellness should consider when exploring the impact of the LE or designing interventions to modify the environment. These include 1) a thoughtful definition and theoretical conceptualization of the LE, 2) clarity about the study variables that are essential to the study question(s), 3) thoughtful and appropriate measurement of those variables, and 4) a study design that balances quality with feasibility. We provide a practical illustration of how these considerations can be applied in studies exploring the intersection of wellness and the LE.

Resident impression management within feedback conversations: A qualitative study

INTRODUCTION

Medical education is moving to conceptualise feedback as a bidirectional learning conversation. Within this conversation, learners experience a tension between assessment and feedback. That perceived tension affects learners' outward performances. In this study, we aimed to characterise residents' experiences with this tension and its effect on learner authenticity within feedback conversations.

METHODS

In this constructivist grounded theory study, the authors were informed by Goffman's theory of impression management. During data analysis, Dweck's theory of mindset was adopted. The authors conducted semi-structured interviews with 15 internal medicine residents. Data collection and analysis were conducted iteratively, using constant comparison to identify themes coinciding with impression management and mindset, ultimately developing a theoretical model to help explain residents' responses to tensions within feedback conversations.

RESULTS

Residents constantly felt 'scrutinized', and this affected their engagement in feedback conversations. They staged a performance within those conversations, linked to their underlying mindset: growth or fixed. Growth mindset was characterised by a focus on development as a physician and was associated with asking questions and seeking opportunities for growth. Fixed mindset was characterised by a focus on achieving a favourable evaluation and was associated with a hesitation to ask questions when faced with uncertainty and admit opportunities for growth, because they were concerned about impression management. Context influenced mindset and impression management. Residents adopted a fixed mindset and managed impressions when they perceived the permanence or consequences of evaluations within feedback. Residents adopted a growth mindset when they trusted the supervisor.

DISCUSSION

Residents assess the context of feedback conversations, altering the authenticity of their behaviours. Context, including the perceptions of formal assessment and relationships with supervisors, affected residents' mindset and impression management. Providing space for relationship-building and clarifying the purpose and structure of assessment may be helpful in supporting effective learning conversations in graduate medical education.