Stability and Change in the Journeys of Medical Trainees: A 9-Year, Longitudinal Qualitative Study

Counternarratives that illuminate faculty agency: A five-year longitudinal qualitative study of physician educators in academic medicine

PURPOSE

Physician educators are often expected to direct educational programs and assume roles that conform to field norms for career advancement but that may not afford meaningful work for educators. The purpose of this study was to describe and analyse the perspectives and actions taken by physician educators in response to tension between feeling compelled to direct an educational program and doing educationally meaningful work.

METHODS AND MATERIALS

We used data from a longitudinal study and focused on three participants who, over the course of the five-year study, offered significant insights into how physician educators act in ways that run counter to expectations for career advancement. Our narrative analysis entailed organizing data from interview transcripts into time-ordered displays, weaving data into counternarratives that were edited by participants, and using the theory of faculty agency (and its key constructs, strategic perspectives and strategic action) to thread the stories together.

RESULTS

In each counternarrative, the participant deliberated their sense of being a physician educator (strategic perspectives) and when expectations became untenable, they did what they needed to do to engage in meaningful work (strategic action) rather than comply with expectations for career advancement in academic medicine. For one participant, faculty agency meant leaving academic medicine; for another, it meant reducing clinical time so that unpaid time could be devoted to education; and for another, it meant opting not do direct a reputable education program.

CONCLUSIONS

Faculty agency is a useful theoretical lens for conceptualizing how physician educators navigate their careers in academic medicine. Counternarratives that illuminate faculty agency offer stories that describe alternate career paths and portend a different future for physician educators.

"Lives and times": The case for qualitative longitudinal research in anatomical sciences education

Qualitative longitudinal research (QLR) focuses on changes in perceptions, interpretations, or practices through time. Despite longstanding traditions in social science, QLR has only recently appeared in anatomical sciences education (ASE). While some existing methodology papers guide researchers, they take a narrow view of QLR and lack specificity for ASE. This discursive article aims to (1) describe what QLR is and its benefits, its philosophies, methodologies and methods, considerations, and quality indicators, and (2) critically discuss examples of QLR in ASE. Underpinned by relativist ontology and subjectivist epistemology, time can be understood as fluid/subjective or fixed/objective. QLR is a flexible, creative, and exploratory methodology, often associated with other methodologies. Sampling is typically purposive, with repeated and recursive data collection methods, and complex three-strand analyses (themes, cases, and time), enabling cross-sectional and longitudinal analyses. QLR involves ethical, relationship, analytical, dissemination, and funding considerations. Key quality indicators relate to qualitative research as well as temporal aspects. Most of the nine ASE papers reviewed explored changes in anatomy learners, but few labeled their methodology as QLR. Just under half described their sampling as purposive, most employed pre-planned and standardized repeated interviews, analyzed their data cross-sectionally, and utilized qualitative data analysis software. Most cited the confirmability and transferability of their studies, but few cited credibility and dependability elements. Study timeframes and tempos were generally clear, but details of longitudinal retention/attrition were often lacking, and longitudinal data analysis was not often conducted. We therefore provide recommendations for the conduct of QLR in ASE.

Researching the application of virtual reality in medical education: one-year follow-up of a randomized trial

BACKGROUND

Compared with traditional tendon repair teaching methods, using a virtual reality (VR) simulator to teach tendon suturing can significantly improve medical students' exercise time, operation flow and operation knowledge. At present, the purpose of this study is to explore the long-term influence of VR simulator teaching on the practice performance of medical students.

METHOD

This is a one-year long-term follow-up study of a randomized controlled study. A total of 117 participants who completed the initial study were invited to participate in the follow-up study. Participants in the VR group and the control group were required to complete a questionnaire developed by the authors and the teachers in the teaching and research department and to provide their surgical internship scores and Objective Structure Clinical Examination(OSCE) graduation scores.

RESULTS

Of the 117 invitees, 108 completed the follow-up. The answers to the questions about career choice and study habits were more positive in the VR group than in the control group (p < 0.05). The total score for clinical practice in the VR group was better than that in the control group, and the difference was statistically significant (p < 0.05). In the OSCE examination, the scores for physical examination, suturing and knotting and image reading were higher in the VR group than in the control group, and the difference was statistically significant (p < 0.05).

CONCLUSION

The results of the one-year long-term follow-up indicated that compared with medical students experiencing the traditional teaching mode, those experiencing the VR teaching mode had more determined career pursuit and active willingness to learn, better evaluations from teachers in the process of surgical clinical practice, and better scores in physical examination, suturing and knotting and image reading in the OSCE examination. In the study of nonlinear dynamics to cultivate a good learning model for medical students, the VR teaching model is expected to become an effective and stable initial sensitive element.

TRIAL REGISTRATION

Chinese Clinical Trial Registry(25/05/2021, ChiCTR2100046648); http://www.chictr.org.cn/hvshowproject.aspx?id=90180 .

Longitudinal exploration of students' identity formation during the transition from pre-clinical to clinical training using research poetry

BACKGROUND

Transitions are critical periods that can lead to growth and, or, distress. Transitions are a sociocultural process, yet most approaches to transitions in practice and research do not explore the social or developmental aspects of entering a new training phase. Wenger reminds us that identity development is crucial when newcomers navigate change. In this paper, we use Wenger's modes of identification: engagement, imagination and alignment to explore students' identity development (as a student and professional) during the transition from pre-clinical to clinical training.

METHODS

We enrolled nine 2nd-year medical students who generated 61 entries comprising audio diary (or typed) reflections over 9 months (starting 3 months before clinical clerkships began) and interviewed them twice. We used research poems (transcripts reframed as poetry) to help construct a meaningful, emotive elicitation of our longitudinal data and analysed data using sensitising concepts from Wenger's modes of identification.

RESULTS

Students described their transition as a journey filled with positive and negative emotions and uncertainty about their current and future careers. Students navigated the transition using three mechanisms: (1) becoming more engaged through taking charge, (2) shaping their image of self through engagement and finding role models and (3) learning to flexibly adapt to clerkship norms by managing expectations and adopting a journey mindset.

CONCLUSIONS

We successfully narrated students' identity formation during their transition to clinical training. We learned that students became more engaged over time by learning to take charge. They shaped their image of self by engaging in team activities and reflecting on role models. They learnt to adapt flexibly to clerkship norms by managing expectations and adopting a journey mindset. We suggest that institutions provide a safe opportunity for medical students to reflect, allowing students' transition periods to be lived, reflected on and supported.

"Finding My Piece in That Puzzle": A Qualitative Study Exploring How Medical Students at Four U.S. Schools Envision Their Future Professional Identity in Relation to Health Systems

PURPOSE

Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation.

METHOD

Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives.

RESULTS

Most students anticipated enacting one or more systems-related roles as a future physician, categorized as "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at a system or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to systems challenges affecting patients; supportive classmates, faculty, and institutional culture). Students also described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences).

CONCLUSIONS

This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings inform practical strategies to support professional identity formation inclusive of systems engagement.

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.

A collaborative clinical case conference model for teaching social and behavioral science in medicine: an action research study

BACKGROUND

Effective social and behavioral sciences teaching in medical education requires integration with clinical experience, as well as collaboration between social and behavioral sciences experts and clinical faculty. However, teaching models for achieving this integration have not been adequately established, nor has the collaboration process been described. This study aims to propose a collaborative clinical case conference model to integrate social and behavioral sciences and clinical experience. Additionally, we describe how social and behavioral science experts and clinical faculty collaborate during the development of the teaching method.

METHODS

A team of medical teachers and medical anthropologists planned for the development of a case conference based on action research methodology. The initial model was planned for a 3-h session, similar to a Clinicopathological Conference (CPC) structure. We evaluated each session based on field notes taken by medical anthropologists and post-session questionnaires that surveyed participants' reactions and points of improvement. Based on the evaluation, a reflective meeting was held to discuss revisions for the next trial. We incorporated the development process into undergraduate medical curricula in clinical years and in a postgraduate and continuous professional development session for residents and certified family physicians in Japan. We repeated the plan-act-observe-reflection process more than 15 times between 2015 and 2018.

RESULTS

The development of the collaborative clinical case conference model is summarized in three phases: Quasi-CPC, Interactive, and Co-constructive with unique structures and underlying paradigms. The model successfully contributed to promoting the participants' recognition of the clinical significance of social and behavioral sciences. The case preparation entailed unique and significant learning of how social and behavioral sciences inform clinical practice. The model development process promoted the mutual understanding between clinical faculty and anthropologists, which might function as faculty development for teachers involved in social and behavioral sciences teaching in medical education.

CONCLUSIONS

The application of appropriate conference models and awareness of their underlying paradigms according to educational situations promotes the integration of social and behavioral sciences with clinical medicine education. Faculty development regarding social and behavioral sciences in medical education should focus on collaboration with scholars with different paradigmatic orientations.

Longitudinal qualitative research in medical education: Time to conceptualise time

CONTEXT

Longitudinal qualitative research is an approach to research that entails generating qualitative data with the same participants over extended periods of time to understand their lived experiences as those experiences unfold. Knowing about dynamic lived experiences in medical education, that is, learning journeys with stops and starts, detours, transitions and reversals, enriches understanding of events and accomplishments along the way. The purpose of this paper is to create access points to longitudinal qualitative research in support of increasing its use in medical education.

METHODS

The authors explore and argue for different conceptualisations of time: analysing lived experiences through time versus analysing lived experiences cross-sectional or via 2-point follow-up studies and considering time as subjective and fluid as well as objective and fixed. They introduce applications of longitudinal qualitative research from several academic domains: investigating development and formal education; building longitudinal research relationship; and exploring interconnections between individual journeys and social structures. They provide an illustrative overview of longitudinal qualitative research in medical education, and end with practical advice, or pearls, for medical education investigators interested in using this research approach: collecting data recursively; analysing longitudinal data in three strands; addressing mutual reflexivity; using theory to illuminate time; and making a long-term commitment to longitudinal qualitative research.

CONCLUSIONS

Longitudinal qualitative research stretches investigators to think differently about time and undertake more complex analyses to understand dynamic lived experiences. Research in medical education will likely be impoverished if the focus remains on time as fixed. Seeing things qualitatively through time, where time is fluid and the past, present and future interpenetrate, produces a rich understanding that can move the field forward.

Exploring health care graduates' conceptualisations of preparedness for practice: A longitudinal qualitative research study

INTRODUCTION

Although preparedness for practice (P4P) has been variously described, little shared understanding exists about what P4P is across the health professions. How P4P is conceptualised matters, because this shapes how stakeholders think, talk about and act towards it. Further, multiple understandings can result in diverse expectations for graduate performance. This study therefore explores health care learners' solicited and unsolicited conceptualisations of P4P over their early graduate transition.

METHODS

We conducted longitudinal qualitative research including individual and group entrance interviews (phase 1: n = 35), longitudinal audio-diaries (phase 2: n = 30), and individual and group exit interviews (phase 3: n = 22) with learners from four disciplines (dietetics, medicine, nursing and pharmacy). We employed framework analysis to interrogate data cross-sectionally and longitudinally.

RESULTS

We found 13 conceptualisations of P4P (eg knowledge, confidence), broadly similar across the disciplines. We found some conceptualisations dominant in both solicited and unsolicited talk (eg skills), some dominant only in solicited talk (eg competence) and others dominant only in unsolicited talk (eg experience). Although most conceptualisations appeared relatively stable across time, some appeared to dominate at certain time points only (eg employability and skills in phases 1 and 2, and competence in phase 3).

DISCUSSION

This novel study extends previous uniprofessional work by illustrating a broader array of conceptualisations, differences between professions, solicited versus unsolicited talk and longitudinal cohort patterns. We encourage health care educators to discuss these different P4P understandings in graduate transition interventions. Further research is needed to explore other stakeholders' conceptualisations, and over a duration beyond the early graduate transition.