The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework

Why impaired wellness may be inevitable in medicine, and why that may not be a bad thing

CONTEXT

A wellness crisis exists among physicians and medical trainees. High rates of burnout, depression, stress and other states of impaired wellness have driven a sense of urgency to create solutions, and the medical education community has mobilised impressively. However, we argue-and data suggest-that this rush to find solutions has outpaced our efforts to more fully understand the nature of impaired wellness in medicine. This, we believe, has led to the implementation of solutions informed by limited understanding of the problems we intend to solve.

METHODS

In this paper, we explore three contributors to this situation: (i) shaky definitions and conceptualisations of wellness, (ii) the predominance of deductive, quantitative research informing our understanding and current solutions, and (iii) the reliance on a 'disease-focused' approach to addressing impaired wellness in physicians and trainees. We discuss how these contributors have led to the current state of the science of wellness in medicine: one characterised by an expanding array of solutions built upon narrow conceptualisations of wellness and how it can be impaired.

DISCUSSION

Moving beyond the current state of the science on wellness in medicine will require three critical developments: (i) consistent use of clear definitions of wellness; (ii) expanding our methodologies to include those utilising direct interaction with participants; and (iii) moving beyond solutions informed by a disease-model approach. We propose a different way of thinking about wellness: one based on what we view as an inherent-and potentially unavoidable-risk of experiencing impairment during a career in medicine. We argue that efforts to extinguish and eliminate all states of impaired wellness may also eliminate opportunities to develop constructive coping mechanisms and future resilience, and that wellness may best be conceptualised as healthy and authentic engagement with the inevitable adversity of a career in medicine.

Educator, judge, public defender: Conflicting roles for remediators of practising physicians

CONTEXT

Practising physicians who remediate their peers face unique challenges. Recent research suggests that leaders of regulatory and educational institutions (ie, those who might be seen as responsible for overseeing remediation programmes for practising physicians) view remediation as a duality: education and regulation. Research has yet to study the perspectives of remediators; therefore, to address that gap we asked: What is the nature of remediation as experienced by remediators?

METHODS

We used a theory-informing inductive data analysis study design with positioning theory as a sensitising concept. We interviewed nine remediators from five Canadian provinces, asking them to narrate particularly memorable remediation experiences, then exploring the stories in more depth by asking probing questions around topics related to the research question. We used a hermeneutic analytic approach to explore the meanings that participants gave to their remediation work by iteratively reading their stories, examining the sense making that participants achieved through these narratives, and identifying the positions and responsibilities they described.

RESULTS

In their remediation narratives, participants variably position themselves in three different ways: (a) educator; (b) judge, and (c) public defender. For each position, remediators in turn framed the remediatee in a particular way. Participants shifted between educator, judge and public defender in response to evolving experiences with the remediatee, but they expressed preference for the educator position. However, they sometimes encountered serious obstacles to enacting that educator position. Those obstacles were imposed both by regulators and by remediatees.

CONCLUSIONS

This study suggests that the duality of remediation as both education and regulation may be contributing to the challenges faced by those working one to one with remediatees. Understanding the dual nature of remediation and equipping remediators with the tools to manage this duality might contribute to improving the experience for both remediators and remediatees, and ultimately to a greater number of successful remediation outcomes.

Understanding the dimensions of a strong-professional identity: a study of faculty developers in medical education

BACKGROUND

Faculty developers are regularly involved in training medical educators to enhance their teaching excellence through workshops and other formats. By exemplifying professional and institutional values, faculty developers may profoundly impact how other educators perceive their own professional identity.

OBJECTIVE

The objective of this study was to understand how the professional identity of faculty developers is formed.

DESIGN

A qualitative approach was used, with a semi-structured interview. The sample consisted of 10 medical educators. A deductive thematic analysis based on Bolivar et al. (2004a) model of professional identity formation for medical educators was carried out.

RESULTS

Self-image was impacted favorably through social recognition from students and peers, and the belief of having demonstrated professional competence through job assignments and enrollment in different leadership positions. The social relations to the center or department in which the faculty developer participates were strongly related to job satisfaction. Expectations about the future of the profession included positive attitudes toward change brought by generational differences. Regarding the process of construction of professional identity, life stories and dissimilar professional careers converge in the same educational setting. Faculty developers regularly resort to self-reflection, with a desire to continue learning and developing. They are resilient and purposeful, even in negative experiences that they have faced as identity crises. They share an awareness in building a legacy for the patients, their families, and the community through nurturing new generations of health-care practitioners.

CONCLUSIONS

The interviewed faculty developers have a strong-professional identity that is characterized by a stable sense of self, strong behavioral repertoire, and key associations with a community of practice.

Exploring perspectives on health professions education scholarship units from sub-Saharan Africa

INTRODUCTION

There has been a marked increase in institutional structures developed to support health professions education scholarship recently. These health professions education scholarship units (HPESUs) engage in a diverse range of activities. Previous work provided insight into factors that influence the functioning of such units, but data from European, Asian, Latin American, and African contexts was absent, potentially leading to a single world-view informing international standards for HPESUs. This aim of this study was to explore perspectives from sub-Saharan Africa (SSA) in response to this omission.

METHODS

Situated within an interpretivist paradigm, the research team conducted semi-structured interviews with nine HPESU leaders in SSA, exploring how participants experienced and understood the functioning of their units. Despite efforts to have representation from across the region, most participants were from South Africa. The researchers analysed data thematically using the theory of institutional logics as an analytical frame.

RESULTS

Several aspects of the HPESUs aligned with the previously identified logics of academic research, service and teaching; and of a cohesive education continuum. By contrast, leaders described financial sustainability as a more prominent logic than financial accountability.

DISCUSSION

The similarities identified in this study may reflect isomorphism-a process which sees institutions within a similar field becoming more alike, particularly as newer institutions seek to acquire legitimacy within that field. An important caveat, however, is that isomorphism tends to occur across similar institutional contexts, which was not the case in this study. Understanding these differences is key as these HPESUs move to foster scholarship that can respond to the region's unique context.

The Hiker's Guide to the RIME Supplement: Choosing Directions in Research

In this Commentary, the authors seek to build on prior RIME commentaries by considering how researchers transition from worldviews, focal lengths, and research goals to research directions and methodological choices. The authors use the analogy of a hiker to illustrate how different researchers studying a similar phenomenon can choose among different research directions, which lead down different paths and offer different perspectives on a problem. Following the hiker analogy, the authors use the "Research Compass" to categorize the 15 research papers included in the 2020 Research in Medical Education supplement according to their research aim and corresponding methodological approach. The authors then discuss implications of the relative balance of these study types within this supplement and within health professions education research at large, emphasizing the critical importance of studying a topic from multiple vantage points to construct a richer and more nuanced understanding of health professions education challenges. The authors conclude by recognizing the challenges we face in the current era of COVID-19 and by calling health professions education researchers and practitioners to continue our collective efforts to improve learner education and patient care, as we together navigate the unfamiliar terrain of the present day.

Scholarly Evaluation of Curricula and Educational Programs: Using a Systematic Approach to Produce Publishable Scholarship

The goal of designing innovative curricula and programs in medical education is to create interventions that will change the attitudes, knowledge, skills, and behaviors of learners in order to prepare them to contribute to the health of patients and communities they serve. Systematic evaluation allows curriculum/program developers to optimize their curriculum/program and ensure that the goals of the curriculum/program are met. While curriculum/program evaluation is distinct from educational research, when approached in a rigorous manner, curriculum/program evaluation can be published as educational scholarship. The goal of our paper is to equip readers with tools to apply a scholarly approach to curriculum/program evaluation to produce findings that will advance the field. We start by defining curricula, educational programs, learner assessment, and evaluation. We then briefly describe examples of best practice models for curriculum/program development that incorporate the critical step of planning for evaluation. Building on published work, we distinguish the use of best practice models and conceptual frameworks to inform curriculum/program development and evaluation. More specifically, we outline steps to plan an evaluation that demonstrates WHAT was effective, describes HOW the curriculum/program contributed to the outcomes achieved, and points to WHY the curriculum/program led to the outcomes observed. We conclude with key considerations for publishing findings of an evaluation, including what to include in each section of a manuscript.

Differences in clerkship development between public and private Brazilian medical schools: an overview

BACKGROUND

Around the world, it is very expensive to become a physician. Although public medical schools are less expensive than private medical schools, tuition fees are charged at public medical schools in the majority of countries. In Brazil, public medical schools, with the exception of municipal schools, are free. There has been little investigation of any differences in conditions offered by paid or free medical schools or what occurs in public and private clerkships in Brazil. We investigated the clerkship conditions offered to the students in both public and private Brazilian medical schools by gathering the opinions of clerkship coordinators and others responsible for clerkships.

METHODS

A cross-sectional, descriptive, analytical study using an electronic questionnaire was answered by clerkship coordinators to compare the clerkships of 30 public and 38 private Brazilian medical schools from all regions of the country. The questionnaires covered various aspects of the clinical environments, student supervision, faculty development, student assessments, rotation evaluations and extracurricular activities developed by students.

RESULTS

We observed significant differences between public and private medical schools in several aspects investigated. Based on the opinions of the clerkship coordinators, with the exception of access to university hospitals, which was predominantly offered by public medical schools, private medical schools offer better clerkship conditions. The main differences were related to the number of positions, infrastructure, clinical learning environments, faculty development, student assessments, rotation evaluations and students' extracurricular activities.

CONCLUSION

This is the first study comparing Brazilian medical clerkships in private and public medical schools and provides a general vision of these programmes. It is necessary to further investigate clerkship development in the Brazilian medical school system and to study the differences between private and public medical schools globally.

Writing for publication: increasing the likelihood of success

The aim of this paper is to help writers at all levels improve their likelihood of success in having papers accepted by academic peer-reviewed journals, including the Journal of Interprofessional Care. We discuss the importance of reading both in your own discipline and also more widely across disciplines and fields of study. There are sections on the attributes of good authors, how to choose a journal, types of articles that are published and the structure of these, the contrast between research and evaluation, and how to plan a paper. We stress the importance of reading and complying with a journal's author guidelines and answering the 'so what' question by the end of the article. There is more detail about the main elements of a paper and what should be included in the introduction, methods, results (findings) and discussion to improve the quality of the reporting. As well as content we also focus on the style of writing. We finish with a discussion of the submission and review processes, why papers may be rejected and how to manage decisions on papers. Dissemination of scholarly work is paramount to the advancement of the interprofessional field; we invite authors to consider our advice and in so doing help strengthen the quality and rigor of interprofessional scholarship.

Development and Validation of a Theory-Informed Group Learning Environment Assessment Tool for Graduate Medical Education Programs

BACKGROUND

Recent studies showed that psychological safety is important to resident perception of the work environment, and improved psychological safety improves resident satisfaction survey scores. However, there is no evidence in medical education literature specifically addressing relationships between psychological safety and learning behaviors or its impact on learning outcomes.

OBJECTIVE

We developed and gathered validity evidence for a group learning environment assessment tool using Edmondson's Teaming Theory and Webb's Depth of Knowledge model as a theoretical framework.

METHODS

In 2018, investigators developed the preliminary tool. The authors administered the resulting survey to neonatology faculty and trainees at Baylor College of Medicine morning report sessions and collected validity evidence (content, response process, and internal structure) to describe the instrument's psychometric properties.

RESULTS

Between December 2018 and July 2019, 450 surveys were administered, and 393 completed surveys were collected (87% response rate). Exploratory factor analysis and confirmatory factor analysis testing the 3-factor measurement model of the 15-item tool showed acceptable fit of the hypothesized model with standardized root mean square residual = 0.034, root mean square error approximation = 0.088, and comparative fit index = 0.987. Standardized path coefficients ranged from 0.66 to 0.97. Almost all absolute standardized residual correlations were less than 0.10. Cronbach's alpha scores showed internal consistency of the constructs. There was a high correlation among the constructs.

CONCLUSIONS

Validity evidence suggests the developed group learning assessment tool is a reliable instrument to assess psychological safety, learning behaviors, and learning outcomes during group learning sessions such as morning report.

Thematic analysis of qualitative data: AMEE Guide No. 131

Thematic analysis is a widely used, yet often misunderstood, method of qualitative data analysis. It is a useful and accessible tool for qualitative researchers, but confusion regarding the method's philosophical underpinnings and imprecision in how it has been described have complicated its use and acceptance among researchers. In this Guide, we outline what thematic analysis is, positioning it in relation to other methods of qualitative analysis, and describe when it is appropriate to use the method under a variety of epistemological frameworks. We also provide a detailed definition of a theme, as this term is often misapplied. Next, we describe the most commonly used six-step framework for conducting thematic analysis, illustrating each step using examples from our own research. Finally, we discuss advantages and disadvantages of this method and alert researchers to pitfalls to avoid when using thematic analysis. We aim to highlight thematic analysis as a powerful and flexible method of qualitative analysis and to empower researchers at all levels of experience to conduct thematic analysis in rigorous and thoughtful way.

Being Edgy in Health Professions Education: Concluding the Philosophy of Science Series

The philosophy of science is concerned with what science is, its conceptual framing and underlying logic, and its ability to generate meaningful and useful knowledge. To that end, concepts such as ontology (what exists and in what way), epistemology (the knowledge we use or generate), and axiology (the value of things) are important if somewhat neglected topics in health professions education scholarship. In an attempt to address this gap, Academic Medicine has published a series of Invited Commentaries on topics in the philosophy of science germane to health professions educational science. This Invited Commentary concludes the Philosophy of Science series by providing a summary of the key concepts that were elucidated over the course of the series, highlighting the intent of the series and the principles of ontology, epistemology, axiology, and methodology. The authors conclude the series with a discussion of the benefits and challenges of cross-paradigmatic research.

"I Had Nobody to Represent Me": How Perceptions of Diabetes Health-Care Providers' Age, Gender and Ethnicity Impact Shared Decision-Making in Adults With Type 1 and Type 2 Diabetes

OBJECTIVES

Our aim in this study was to investigate how patients' perceptions of their diabetes health-care providers' (HCP) age, gender and ethnicity impact shared decision-making using the Theory of Planned Behaviour.

METHODS

Adult participants receiving diabetes care at community sites, primary care or specialty clinics participated in semistructured, one-on-one interviews conducted from November 2018 to January 2019. Responses were transcribed and qualitatively analyzed for emergent themes using statistical software (NVivo version 9).

RESULTS

We conducted 28 interviews with participants 34 to 81 years of age. The following themes were identified: 1) participants' gestalt of their diabetes HCP was strongly gender dependent 2) there was a hidden preference for Caucasian HCPs, 3) age evoked a less defensive response with regard to shared decision-making and 4) degree of trust in self and in their diabetes HCP directed participants' readiness to be part of the shared decision-making.

CONCLUSIONS

Participants' narrative experiences strongly suggest that they view their diabetes HCPs through a gendered and racialized lens.

Tools for Medical Education Scholarship: From Curricular Development to Educational Research

The development of successful educational scholarship, either curricula or medical education research, is vital in ensuring that the field of medical education continues to evolve. Fostering the skills of medical educators in conducting high-quality educational research is essential to this process because publishing such research helps to disseminate best educational practices to the medical community at large. Unfortunately, developing rigorous medical education research can be challenging for pediatric hospitalists within busy clinical settings. In this article, we aim to discuss key principles and frameworks for curricular development as well as offer guidance in transforming a curriculum into a scholarly medical education research product for pediatric hospital medicine providers.

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

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

The utility of failure: a taxonomy for research and scholarship

INTRODUCTION

Health professions education (HPE) research and scholarship utilizes a range of methodologies, traditions, and disciplines. Many conducting scholarship in HPE may not have had the opportunity to consider the value of a well-designed but failed scholarly project, benefitted from role-modelling of the value of failure, nor have engaged with the common nature of failure in research and scholarship.

METHODS

Drawing on key concepts from philosophy of science, this piece describes the necessity and benefit of failure in research and scholarship, presents a taxonomy of failure relevant to HPE research, and applies this taxonomy to works published in the Perspectives on Medical Education failures/surprises series.

RESULTS

I propose three forms of failure relevant to HPE scholarship: innovation-driven, discovery-oriented, and serendipitous failure. Innovation-driven failure was the most commonly represented type of failure in the failures/surprises section, and discovery-oriented the least common.

CONCLUSIONS

Considering failure in research and scholarship, four conclusions are drawn. First, failure is integral to research and scholarship-it is how theories are refined, discoveries are made, and innovations are developed. Second, we must purposefully engage with the opportunities that failure provide-understanding why a particular well-designed project failed is an opportunity for further insight. Third, we must engage publicly with failure in order to better communicate and role model the complexities of executing scholarship or innovating in HPE. Fourth, in order to make failure truly an opportunity for growth, we must, as a community, humanize and normalize failure as part of a productive scholarly approach.