Medicine as a Community of Practice: Implications for Medical Education

Development of a national medical leadership competency framework: the Dutch approach

BACKGROUND

The concept of medical leadership (ML) can enhance physicians' inclusion in efforts for higher quality healthcare. Despite ML's spiking popularity, only a few countries have built a national taxonomy to facilitate ML competency education and training. In this paper we discuss the development of the Dutch ML competency framework with two objectives: to account for the framework's making and to complement to known approaches of developing such frameworks.

METHODS

We designed a research approach and analyzed data from multiple sources based on Grounded Theory. Facilitated by the Royal Dutch Medical Association, a group of 14 volunteer researchers met over a period of 2.5 years to perform: 1) literature review; 2) individual interviews; 3) focus groups; 4) online surveys; 5) international framework comparison; and 6) comprehensive data synthesis.

RESULTS

The developmental processes that led to the framework provided a taxonomic depiction of ML in Dutch perspective. It can be seen as a canonical 'knowledge artefact' created by a community of practice and comprises of a contemporary definition of ML and 12 domains, each entailing four distinct ML competencies.

CONCLUSIONS

This paper demonstrates how a new language for ML can be created in a healthcare system. The success of our approach to capture insights, expectations and demands relating leadership by Dutch physicians depended on close involvement of the Dutch national medical associations and a nationally active community of practice; voluntary work of diverse researchers and medical practitioners and an appropriate research design that used multiple methods and strategies to circumvent reverberation of established opinions and conventionalisms.

IMPLICATIONS

The experiences reported here may provide inspiration and guidance for those anticipating similar work in other countries to develop a tailored approach to create a ML framework.

Communities of Practice in Peer Review: Outlining a Group Review Process

Traditional peer review remains the gold standard for assessing the merit of scientific scholarship for publication. Challenges to this model include reliance on volunteer contributions of individuals with self-reported expertise; lack of sufficient mentoring and training of new reviewers; and the isolated, noncollaborative nature of individual reviewer processes.The authors participated in an Association of American Medical Colleges peer-review workshop in November 2015 and were intrigued by the process of group peer review. Subsequent discussions led to shared excitement about exploring this model further. The authors worked with the staff and editors of Academic Medicine to perform a group review of 4 submitted manuscripts, documenting their iterative process and analysis of outcomes, to define an optimal approach to performing group peer review.Individual recommendations for each manuscript changed as a result of the group review process. The group process led to more comprehensive reviews than each individual reviewer would have submitted independently. The time spent on group reviews decreased as the process became more refined. Recommendations aligned with journal editor findings. Shared operating principles were identified, as well as clear benefits of group peer review for reviewers, authors, and journal editors.The authors plan to continue to refine and codify an effective process for group peer review. They also aim to more formally evaluate the model, with inclusion of feedback from journal editors and authors, and to compare feedback from group peer reviews versus individual reviewer feedback. Finally, models for expansion of the group-peer-review process are proposed.

Social Interactions of Clerks: The Role of Engagement, Imagination, and Alignment as Sources for Professional Identity Formation

PURPOSE

Participating in clinical practice shapes students' identities, but it is unclear how students build meaningful relationships while "dipping into" various social contexts. This study explored with whom students interacted, which social relationships they built, and how these relationships contributed to the formation of a professional identity.

METHOD

In this longitudinal study at University Medical Center Groningen, University of Groningen, the Netherlands, 9 undergraduate medical students recorded experiences of thinking about themselves as future professionals (September 2015 to March 2017). The authors conducted template analysis using both open coding and a priori themes derived from Wenger's modes of belonging to communities of practice: engagement, imagination, and alignment.

RESULTS

The authors received 205 recorded experiences. While rotating, students used engagement, imagination, and alignment to give meaning to clinical workplace social interactions. Participants considered relationships with doctors, patients, and peers as preconditions for engaging in meaningful experiences. Although imagination and alignment were less represented, discussing imagination with peers and physicians stimulated a deeper understanding of what it means to become a physician. Explicitly being invited "to the table" and awareness of the benefits of being a clerk were instances of alignment that stimulated the development of identities as future doctors.

CONCLUSIONS

To understand the nature of professional identity formation, Wenger's modes of belonging must be considered. Where engagement is very prevalent, imagination and alignment are less spontaneously mentioned and therefore more difficult to foster. Looking for ways to support imagination and alignment is important for students' sensemaking process of becoming a doctor.

Disentangling residents' engagement with communities of clinical practice in the workplace

Maximising the potential of the workplace as a learning environment entails understanding the complexity of its members' interactions. Although some articles have explored how residents engage with supervisors, nurses and pharmacists individually, there is little research on how residents enter into and engage with the broader community of clinical practice (CoCP). To this end, we designed a constructivist grounded theory study that took place at Universidad Javeriana in Bogotá, Colombia. We conducted semi-structured interviews with 13 residents from different training levels and disciplines during the first weeks of their new rotations. During the interviews, we used the Pictor technique as a visual aid to collect data. Using iterative data collection and analysis, constant comparison methods and theoretical sampling, we constructed the final results. When entering a CoCP, residents experienced recurring and intertwined processes including: exploring how their goals and interest are aligned with those of the CoCP; identifying the relevant CoCP members in the workplace environment; and understanding how these members could assist their successful engagement with the community's practices. Residents entered a CoCP with the intention of either having a central or a peripheral trajectory in it. The final resident participation and role resulted from negotiations between the resident and the CoCP members. Optimising workplace learning includes being mindful as to how each member of the healthcare team influence residents' engagement on practice, and on understanding the nuances of residents' participatory trajectories while interacting with them. Understanding such nuances could be key to align CoCPs' learning affordances and residents' goals and intentions.

Supporting the development of a professional identity: General principles

While teaching medical professionalism has been an important aspect of medical education over the past two decades, the recent emergence of professional identity formation as an important concept has led to a reexamination of how best to ensure that medical graduates come to "think, act, and feel like a physician." If the recommendation that professional identity formation as an educational objective becomes a reality, curricular change to support this objective is required and the principles that guided programs designed to teach professionalism must be reexamined. It is proposed that the social learning theory communities of practice serve as the theoretical basis of the curricular revision as the theory is strongly linked to identity formation. Curricular changes that support professional identity formation include: the necessity to establish identity formation as an educational objective, include a cognitive base on the subject in the formal curriculum, to engage students in the development of their own identities, provide a welcoming community that facilitates their entry, and offer faculty development to ensure that all understand the educational objective and the means chosen to achieve it. Finally, there is a need to assist students as they chart progress towards becoming a professional.

The Integration of Clinical and Research Training: How and Why MD-PhD Programs Work

For over 60 years, MD-PhD programs have provided integrated clinical and research training to produce graduates primed for physician-scientist careers. Yet the nature of this integrated training is poorly characterized, with no program theory of MD-PhD training to guide program development or evaluation. The authors address this gap by proposing a program theory of integrated MD-PhD training applying constructs from cognitive psychology and medical education. The authors argue that integrated physician-scientist training requires development of at least three elements in trainees: cognitive synergy, sense of self, and professional capacity. First, integrated programs need to foster the cognitive ability to synergize and transfer knowledge between the clinical and research realms. Second, integrated programs need to facilitate development of a unique and emergent identity as a physician-scientist that is more than the sum of the individual roles of physician and scientist. Third, integrated programs should develop core competencies unique to physician-scientists in addition to those required of each independently. The authors describe how programs can promote development of these elements in trainees, summarized in a logic model. Activities and process measures are provided to assist institutions in enhancing integration. Specifically, programs can enact the proposed theory by providing tailored MD-PhD curricula, personal development planning, and a supportive community of practice. It is high time to establish a theory behind integrated MD-PhD training as the basis for designing interventions and evaluations to develop the foundations of physician-scientist expertise.

Practical Implications of Compassionate Off-Ramps for Medical Students

Attrition from medical school remains uncommon even when a medical student performs poorly, has a change in interests, or experiences an unexpected life event that alters his/her ability to succeed as a physician. In this issue, Bellini and colleagues describe the scope of this problem and make recommendations to support the implementation of compassionate off-ramps for students. These recommendations include enabling ongoing assessment of commitment to career path via a professional identity formation curriculum; implementing competency-based education and training to identify struggling learners; using career advisors and coaches who understand alternative career pathways; providing credit or credentials for competencies already achieved; requiring financial counseling and supporting debt forgiveness; and requiring schools to report on their remediation programs and handling of debt. In this Invited Commentary, the authors describe a representative student-a composite of several students they have counseled whose medical school paths have been impacted by poor performance, unanticipated life events and stressors, changing career interests, and/or physical and mental health issues-who may have benefited from these recommendations. The authors elaborate on Bellini and colleagues' recommendations and describe what they think would be necessary to ensure that the recommendations effectively meet the goal of providing compassionate off-ramps for students in need. The authors describe the potential impact of the recommendations on the representative and similar students. Although this impacts a small proportion of students, the recommendations would help schools achieve the moral imperatives of humanistic care for students while honoring the social contract of the medical profession.

Challenging encounters as experienced by registered nurses new to the emergency medical service: explored by using the theory of communities of practice

The aim of this study was to explore challenging encounters experienced by registered nurses (RN) during their first year in the emergency medical service by using the social learning theory of communities of practice. During the first year in a new professional practice, a new RN experiences a transition during which the new professional identity is being formed. This is a challenging and demanding period of time. According to the learning theory of communities of practice by Lave and Wenger, individuals' learning and development in a new professional practice occurs through participation in social activity and is influenced by context. This study is based on the qualitative data from semi-structured interviews. Thirty-two RNs working in the Swedish emergency medical service were interviewed via telephone during the spring of 2017. A qualitative content analysis with deductive reasoning of the interviews was used. The analysis process generated the main category; New RNs participation is challenged by unpredictability and uncertainty in practice. The main category was based on three generic categories; Loneliness in an unpredictable context, Uncertainty about the team, and Uncertainty in action. The challenges new RNs encounter during the first year relate to all three dimensions of a community of practice; mutual engagement, joint enterprise and shared repertoire. The encountered challenges also relate to the EMS context. Taking into account all these aspects when designing support models for RN's professional development may be advantageous for creating positive development for RNs new to the EMS and/or similar practices.

A Road Map for Attending to Medical Students' Professionalism Lapses

PURPOSE

To develop a road map for educators attending to medical students' professionalism lapses, aiming to offer an empirical base for approaching students who display such lapses.

METHOD

Between October 2016 and January 2018, 23 in-depth interviews with 19 expert faculty responsible for remediation from 13 U.S. medical schools were conducted about the way they handle students' professionalism lapses. Three researchers independently completed three rounds of coding. Data collection, coding, and analysis were performed in a constant comparative process. A constructivist grounded theory approach was used to develop an explanatory model for attending to students' professionalism lapses.

RESULTS

Based on participants' descriptions, the authors developed a three-phase approach for attending to professionalism lapses. In phase 1, experts enacted the role of concerned teacher, exploring the lapse from the student's perspective. In phase 2, they functioned as supportive coach, providing feedback on professionalism values, improving skills, creating reflectiveness, and offering support. In phase 3, if the student did not demonstrate reflectiveness and improvement, and especially if (future) patient care was potentially compromised, participants assumed an opposite role: gatekeeper of the profession.

CONCLUSIONS

An explanatory model for attending to professionalism lapses that fits in the overarching "communities of practice" framework was created. Whereas phase 1 and 2 aim at keeping students in the medical community, phase 3 aims at guiding students out. These findings provide empirical support to earlier descriptive, opinion-based models and may offer medical educators an empirical base for attending to students who display professionalism lapses.

Curricular Development and Implementation of a Longitudinal Integrative Medicine Education Experience for Trainees and Health-Care Professionals at an Academic Medical Center

A growing number of patients and consumers are seeking integrative medicine (IM) approaches as a result of increasing complex medical needs and a greater emphasis on prevention and health promotion. Health-care professionals need to have knowledge of the evidence-based IM resources that are safe and available to patients. Medical institutions have acknowledged the need for education and training in various IM modalities and whole-health approaches in medical curricula. There is a strong need to develop and incorporate well-structured IM curricula across all levels of learning and practice within medicine. This article provides an example of the development, implementation, impact, and assessment of IM education curricula across all learner levels at a large academic medical center.

The Evolution of the Clinician-Educator in the United States and Canada: Personal Reflections Over the Last 45 Years

The challenging and changing face of medicine over the last 45 years of the author's career has dictated where faculty members' primary interaction with patients occurs, how they teach trainees, and how they measure educational outcomes. The transfer of patient care from the inpatient to the ambulatory setting in the late 20th century was instrumental in creating a "new' model for faculty-that is, the clinician-educator (CE). This individual has been defined as a faculty member whose primary responsibility as part of the academic mission is patient care and whose focus is on the theoretical constructs that inform excellent teaching and effective learning, applying these to create and inform educational scholarship. Three major forces have affected the CE over time-namely, faculty development, educational scholarship, and the advent of communities of learners. This Invited Commentary traces the evolvement of the CE from the perspective of the author.

A Novel Web-Based Experiential Learning Platform for Medical Students (Learning Moment): Qualitative Study

BACKGROUND

Experiential learning plays a critical role in learner development. Kolb's 4-part experiential learning model consists of concrete experience, reflective observation, abstract conceptualization, and active experimentation in a recurring cycle. Most clinical environments provide opportunities for experiences and active experimentation but rarely offer structured means for reflection and abstract conceptualization that are crucial for learners to learn through experience. We created Learning Moment, a novel Web-based educational tool that integrates principles of asynchronous learning and learning portfolios to fulfill the reflection and abstract conceptualization aspects of Kolb's learning cycle in the modern clinical learning environment. Medical students log concise clinical "pearls" in the form of "learning moments" for reflection, review, and sharing with peers in a community of practice.

OBJECTIVE

We sought to evaluate learners' experiences with Learning Moment via a qualitative study.

METHODS

We employed purposive sampling to recruit medical students who used Learning Moment during their rotation. We conducted 13 semistructured interviews (10 individual interviews and one 3-person group interview) between January and March 2017 using an ethnographic approach and utilized a general inductive method to analyze and code for potential themes.

RESULTS

A total of 13 students (five in their third year of medical school and eight in their fourth year) voluntarily participated in our qualitative interviews. Five of the 13 (38%) students intended to pursue emergency medicine as their chosen field of specialty. The median number of "learning moments" logged by these students is 6. From our analysis, three key themes emerged relating to the perceived impact of Learning Moment on student learning: (1) logging "learning moments" enhanced memorization, (2) improved learning through reflection, and (3) sharing of knowledge and experiences in a community of practice.

CONCLUSIONS

Learning Moment was successfully implemented into the educational infrastructure in our department. Students identified three mechanisms by which the application optimizes experiential learning, including enabling the logging of "learning moments" to promote memorization, encouraging reflection to facilitate learning, and fostering the sharing of knowledge and experiences within a community of practice. The Learning Moment concept is potentially scalable to other departments, disciplines, and institutions as we seek to optimize experiential learning ecosystems for all trainees.

Understanding Clerkship Student Roles in the Context of 21st-Century Healthcare Systems and Curricular Reform

Phenomenon: Preclerkship medical education has undergone extensive reform, and the clerkship years are growing targets for curricular innovation. As institutions implement new preclerkship curricula to better prepare medical students to practice medicine in the context of modern healthcare systems, the perspective of clerkship leaders regarding clerkship student roles and potential for change will facilitate redefining these roles so that preclerkship educational innovations can continue into clerkships. Approach: In this qualitative exploratory study, authors conducted semistructured interviews with clerkship and site directors for eight core clerkships from April to May 2016. Questions addressed how clerkship leaders perceive current student roles and the potential for change. Through iterative consensus building, authors identified themes describing current ideal clerkship student roles applicable to future roles. Findings: Twenty-three of 24 (96%) directors participated. Findings fell into four themes: factors influencing the clerkship role, clerkship student role archetypes, workplace authenticity and value, and potential for change. Student, supervisor, and context factors determine the clerkship student role. Three role archetypes emerged: the apprentice (an assistant completing concrete patient care tasks), the academic (a researcher bringing literature back to the team), and the communicator (an interdisciplinary and patient liaison). Each archetype was considered authentic and valuable. Positive attitudes toward preclerkship curricular changes were associated with openness to evolution of the clerkship students' role. These emerging roles mapped to the archetypes. Insights: Clerkship leaders perceive that student, supervisor, and context factors result in varying emphasis on role archetypes, which in turn lead to different types of learning. Medical educators can use the archetypes to articulate how expanded student roles align learning with clinical needs, particularly as they relate to health systems science and inquiry.

Faculty Development Revisited: A Systems-Based View of Stakeholder Development to Meet the Demands of Entrustable Professional Activity Implementation

In 2015, the Association of American Medical Colleges implemented an interinstitutional pilot of 13 core entrustable professional activities (EPAs) for entering residency, activities that entering residents should be expected to perform with indirect supervision. The pilot included a concept group on faculty development; this group previously offered a shared mental model focused on the development of faculty who devote their efforts to clinical teaching and assessment for learning and entrustment decision making. In this article, the authors draw from the literature of competency-based education to propose what is needed in overall approaches to faculty development to prepare institutions for undergraduate EPA implementation.Taking a systems-based view that defines the necessary tasks of EPA implementation, the authors move beyond the variably used term "faculty" and enumerate a comprehensive list of institutional stakeholders who can meaningfully support and/or engage in the relationships and organizational processes required for EPA learning and assessment. They consider each group's responsibilities and development needs according to five domains delineated by Steinert: teaching improvement, leadership and management, research-building capacity, academic career building, and organizational change.The authors argue that the EPA framework addresses barriers posed with the use of a competency-based framework. By facilitating the communication required for organizational change, enabling valid assessment with comprehensive yet feasible levels of faculty development, and incorporating all relevant data on student professional behavior into summative assessment decisions, EPAs may offer a clearer path toward the goal of competency-based education.

Ethical dilemma of identity disclosure faced by medical students in clinical clerkships: A nationwide multicenter study in China

Objective

Medical students in China are currently facing a dilemma of whether to clarify their identity as students to patients. Further investigation is needed to support policy-making. The aim was to identify factors influencing medical students’ decision on whether or not to clarify their identity to patients and to examine the effects of their decision.

Methods

The study was a cross-sectional nationwide multicenter survey consisting of 947 medical students. A self-designed questionnaire was composed of 19 structured questions investigating the present situation and participants’ perception of the ethical dilemma surrounding medical student identity. The questionnaires were distributed randomly in teaching hospitals affiliated with 13 medical schools across China from June 2015 to January 2016.

Results

A total of 947 valid questionnaires were retrieved with a valid response rate of 83.7%. Most medical students (71.4%) tended to be ambiguous about their student identity in front of patients. The frequency of encountering distrust and patients’ or patient relatives’ refusal to allow students to perform procedures was significantly lower for students who explicitly stated their identity than for those who were ambiguous about their identity (p<0.001). Less experience in clinical rotations (<0.5 y/0.5–1 y, OR 2.7, 95% CI 1.7–4.3; <0.5 y/>1 y, OR 3.6, 95% CI 2.0–6.5), preceptors’ straightforward introduction of the students (OR 8.7, 95% CI 5.4–13.8) and students’ acknowledgment of patients’ right to know (OR 2.3, 95% CI 1.2–4.5) were related to students’ clear self-introduction to patients.

Conclusion

It is beneficial for medical students to clearly explain their identity to patients in order to decrease patient distrust and prevent the refusal to have certain appropriate procedures performed. Several methods, including emphasizing the role of mentors, developing curriculum for medical students, and creating clear regulations and guidelines for revealing the identity of medical students on the healthcare team can help address and ideally resolve this ethical dilemma of identity disclosure.

How Mentor Identity Evolves: Findings From a 10-Year Follow-up Study of a National Professional Development Program

PURPOSE

Despite academic medicine's endorsement of professional development and mentoring, little is known about what junior faculty learn about mentoring in implicit curricula of professional development programs, and how their mentor identity evolves in this context. The authors explored what faculty-participants in the Educational Scholars Program implicitly learned about mentoring and how the implicit curriculum affected mentor identity transformation.

METHOD

Semistructured interviews with 19 of 36 former faculty-participants were conducted in 2016. Consistent with constructivist grounded theory, data collection and analysis overlapped. The authors created initial codes informed by Ibarra's model for identity transformation, iteratively revised codes based on incoming data patterns, and created visual representations of relationships amongst codes to gain a holistic, shared understanding of the data.

RESULTS

In the implicit curriculum, faculty-participants learned the importance of having multiple mentors, the value of peer mentors, and the incremental process of becoming a mentor. The authors used Ibarra's model to understand how the implicit curriculum worked to transform mentor identity: Faculty-participants reported observing mentors, experimenting with different ways to mentor and to be a mentor, and evaluating themselves as mentors.

CONCLUSIONS

The Educational Scholars Program's implicit curriculum facilitated faculty-participants taking on mentor identity via opportunities it afforded to watch mentors, experiment with mentoring, and evaluate self as mentor, key ingredients for identity construction. Leaders of professional development programs can develop faculty as mentors by capitalizing on what faculty-participants learn in the implicit curriculum and deliberately structuring postgraduation mentoring opportunities.

A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education

BACKGROUND

Physicians need to rapidly and effectively facilitate patient-centered, shared decision-making (SDM) conversations, but little is known about how residents or attending physicians acquire this skill.

OBJECTIVE

We explored emergency medicine (EM) attending physicians' use of SDM in the context of their experience as former residents and current educators and assessed the implications of these findings on learning opportunities for residents.

METHODS

We used semistructured interviews with a purposeful sample of EM physicians. Interviews were transcribed verbatim, and 3 research team members performed iterative, open coding of transcripts, building a provisional codebook as work progressed. We analyzed the data with a focus on participants' acquisition and use of skills required for SDM and their use of SDM in the context of resident education.

RESULTS

Fifteen EM physicians from academic and community practices were interviewed. All reported using SDM techniques to some degree. Multiple themes noted had negative implications for resident acquisition of this skill: (1) the complex relationships among patients, residents, and attending physicians; (2) residents' skill levels; (3) the setting of busy emergency departments; and (4) individual attending factors. One theme was noted to facilitate resident education: the changing culture-with a cultural shift toward patient-centered care.

CONCLUSIONS

A constellation of factors may diminish opportunities for residents to acquire and practice SDM skills. Further research should explore residents' perspectives, address the modifiable obstacles identified, and examine whether these issues generalize to other specialties.

Preparing Interprofessional Faculty to Be Humanistic Mentors for Medical Students: The GW-Gold Mentor Development Program

INTRODUCTION

The GW-Gold Humanistic Mentor Development Program addresses the challenge faced by medical schools to educate faculty to prepare students for humanistic practice. Grounded in Branch's Teaching Professional and Humanistic Values model, the program prepares interprofessional faculty mentoring teams in humanistic communities of practice. The teams consist of physician-psychosocial professional pairs, each mentoring a small student group in their professional development course. Through GW-Gold workshops, faculty mentors develop interprofessional humanistic communities of practice, preparing them to lead second such communities with their students. This article describes the program and its evaluation.

METHODS

To assess outcomes and better understand the mentor experience, we used a mixed-method validating triangulation design consisting of simultaneous collection of quantitative (mentor and student surveys) and qualitative (open-ended survey questions and focus group) data. Data were analyzed in parallel and merged at the point of interpretation, allowing for triangulation and validation of outcomes.

RESULTS

Mentors rated the program highly, gained confidence in their humanistic skills, and received high scores from students. Three themes emerged that validated program design, confirmed outcomes, and expanded on the mentor experience: (1) Interprofessional faculty communities developed through observation, collaboration, reflection, and dialogue; (2) Humanistic mentors created safe environments for student engagement; and (3) Engaging in interprofessional humanistic communities of practice expanded mentors' personal and professional identities.

DISCUSSION

Outcomes support the value of the GW-Gold program's distinctive features in preparing faculty to sustain humanism in medical education: an interprofessional approach and small communities of practice built on humanistic values.