Making space to learn about teaching: expanding teaching horizons through postgraduate education

Clinicians develop as teachers via many activities, from on-the-job training to formal academic programmes. Yet, understanding how clinicians develop the sensibilities of an educator and an appreciation of the complexity of educational environments is challenging. Studies of teacher development have maintained a relatively narrow definition of educational practice. A more expansive view encompasses clinical teachers' roles in relation to elements beyond learners or content, such as the cultures and other structures of healthcare institutions. In our online Postgraduate Certificate in Clinical Education, space and structure are intentionally created for teachers to think and talk about education with colleagues in other disciplinary contexts. We interviewed 17 students about how their approaches to teaching had changed over a year of part-time study, using their teaching philosophies, written at the start of the programme, as points of contrast. We took an abductive approach to data analysis, drawing on the literature and, unavoidably, our own reflexive interpretations of our practice outside of the research context, such as conversations with students and colleagues; our experiences of teaching and our concurrent research and scholarship. Our themes of repertoire building, perspective shifting, embodied practice, and appreciation of context, describe the increasing complexity of individuals' considerations of teaching. We use our analysis as the basis for a discussion of the blurring of boundaries between staff and students on such programmes as both groups are engaged in an ongoing continuum of development as all teachers, continue to be learners of educational practice. These insights can inform the ways in which postgraduate programmes can make space for clinical teachers to share and reflect on practices, perspectives and contexts.

Heard, valued, supported? Doctors' wellbeing during transitions triggered by COVID-19

INTRODUCTION

Supporting doctors' wellbeing is crucial for medical education to help minimise negative long-term impacts on medical workforce retention and ultimately patient care. There is limited study of how doctors' transitions experiences impact wellbeing, particularly socially and culturally. Multiple Multidimensional Transitions (MMT) theory views transitions as dynamic, incorporating multiple contexts and multiple domains. Using MMT as our lens, we report a qualitative analysis of how transitions experienced by doctors during the pandemic impacted on social and cultural aspects of wellbeing.

METHODS

Longitudinal narrative inquiry was employed, using interviews and audio-diaries. Data were collected over 6 months in three phases: (i) interviews with doctors from across the career spectrum (n = 98); (ii) longitudinal audio-diaries for 2-4 months (n = 71); (iii) second interviews (n = 83). Data were analysed abductively, narrowing focus to factors important to social and cultural wellbeing.

RESULTS

Doctors described experiencing multiple interacting transitions triggered by the pandemic in multiple contexts (workplace, role, homelife and education). Patterns identifiable across the dataset allowed us to explore social and cultural wellbeing crosscutting beyond individual experience. Three critical factors contributed to social and cultural wellbeing both positively and negatively: being heard (e.g., by colleagues asking how they are); being valued (e.g., removal of rest spaces by organisations showing lack of value); and being supported (e.g., through regular briefing by education bodies).

CONCLUSIONS

This study is the first to longitudinally explore the multiple-multidimensional transitions experienced by doctors during the COVID-19 pandemic. Our data analysis helped us move beyond existing perceptions around wellbeing and articulate multiple factors that contribute to social and cultural wellbeing. It is vital that medical educators consider the learning from these experiences to help pinpoint what aspects of support might be beneficial to trainee doctors and their trainers. This study forms the basis for developing evidenced-based interventions that ensure doctors are heard, valued and supported.

How can inhabited institutionalism inform the analysis of medical education?

CONTEXT

Medical schools are complex organisations existing at the intersection of higher education and healthcare services. This complexity is compounded by many competing pressures and drivers from professional and regulatory bodies, the wider political environment and public expectations, producing a range of challenges for those involved in all stages of medical education. There are established approaches that have been used to address research questions related to these challenges; some focus on organisational structures, characteristics and performance; others on the interactions that take place in a particular setting. Less common are approaches that integrate data on macro-level structures with the micro-level interactions of the people who inhabit those structures. Looking at the interaction of the macro and the micro opens up possibilities for the new insights.

FRAMEWORK

We propose using an approach with roots in social theory-Inhabited Institutionalism (II)-that is largely unexplored in medical education. II has been described as Janus-faced, looking both outwards, at the broader context of medical education, and inwards, at the ways in which meanings are constructed and re-constructed by participants within a particular setting.

METHODS

After describing the theoretical framework of II, we explain how it can be used to understand medical education as subject to both broader societal structures (the macro level) and interactions between people (the micro level), as well as-crucially-their mutual influence.

CONCLUSION

II offers the opportunity to combine macro- and micro-level perspectives, leading to a more expansive understanding of the operation of medical education which sees its form and function as neither entirely determined by structures nor a construction of individuals engaged in it. In doing so, it potentially offers a valuable way of considering the intractable problem of how to successfully manage change, offering a combined top-down and bottom-up perspective.

What can we learn from the online learning experiences of medical students in Poland during the SARS-CoV-2 pandemic?

BACKGROUND

In March 2020, due to the SARS-CoV-2 pandemic, the Polish government ordered the closing of all medical faculties, with an obligatory shift to online learning. This lockdown continued, with a short period of blended learning, over the time of summer 2020. Distance learning had previously been rarely used within Polish medical schools, so such a sudden transfer was a major challenge. The aim of the study was to explore undergraduates' perception of online teaching provided at Polish medical faculties during the pandemic and to analyze how these experiences may inform future curriculum development.

METHODS

The online survey was addressed to undergraduates at Polish medical faculties in November 2020. The questions captured demographics, epidemiological data and students' perception of various aspects of online teaching. Responses were subjected to thematic analysis and their distribution compared considering demographic parameters .

RESULTS

Six hundred twenty students from thirteen medical faculties responded to the survey. Major benefits from online teaching perceived by respondents included increased convenience, enhanced quality, a sense of comfort and safety. Major complaints were associated with unsatisfactory content, technical issues, difficulties engaging, poor organization and lack of social life. Students claimed that online teaching required more self-directed learning and discipline and 57.9% considered this impact as negative. 44.5% of respondents took part in educational online activities beyond their scheduled classes. For 49.2% online examinations were reported as more stressful and for 24.8% - less stressful than traditional ones. Differences in the opinions on online teaching were found between men and women, students in early and senior years, Polish and non-Polish ones.

CONCLUSIONS

The sudden move online inevitably was problematic for students. Their perspective afforded us the opportunity to consider shortcomings of pre-pandemic undergraduate curriculum. Online education requires a more self-directed learning, which was challenging for many students, so further enhancement of more autonomous study skills seems necessary. Distress expressed by students indicates the need for urgent support with mental health issues.

Challenging assumptions about "moving online" in response to COVID-19, and some practical advice

This article was migrated. The article was marked as recommended. COVID-19 is forcing many Universities to close for some time and programmes for medical, allied health, and nursing students are moving online. Based on our extensive collective experience teaching a variety of health professionals in clinical and academic settings, and of online learning, we want to question assumptions that seem apparent to us in some of the discourse around "moving teaching online". We write from the perspective of a team delivering a postgraduate programme for professionals working full time (in most cases) from around the world and different professions; however, we believe the issues raised are applicable to online education in general. There is a practical purpose to confronting these assumptions. It is our aim to help those delivering health professions education avoid some pitfalls that we think would result in poor quality experiences for all concerned. We do not believe that online education is inherently poorer nor, indeed, fundamentally distinct from on-campus education. However, there are certainly important considerations for learning to teach online, and we attempt to highlight some of these. We also provide some advice to those new to teaching online based on our experience, research, and the literature.

Using a theoretical framework to develop postgraduate health professions education research and practice

This article was migrated. The article was marked as recommended. Healthcare education is complex and multifaceted, requiring study from different angles and with different lenses. We propose that the use of a meta-framework can help those teaching and researching postgraduate health professions education make holistic sense of their practice and findings from different projects. We discuss how we have employed Bronfenbrenner's ecological systems theory (EST) as an overarching theoretical framework for the scholarship of learning and teaching in the context of postgraduate health professions education. Taking a structured approach to pedagogical thinking and research through the use of a meta-framework opens up useful ways of framing findings and further questions, locating research projects within a bigger picture, and communicating to others the focus of a research programme. We address the problem of the under-theorizing of educational research in postgraduate health professions education, advocating both theoretical frameworks for individual research projects, and an overarching theoretical "meta-framework" to interrogate and draw together multiple studies. In doing so we build on, critique and further develop Bronfenbrenner's ecological systems theory.

Using Bourdieu to explore graduate attributes in two online Master's programmes

Within the expansion of postgraduate educational qualifications for health professionals, graduate attributes have become important markers of outcomes and value. However, it is not clear how or when graduate attributes develop, or how they are applied in professional practice after graduation. We interviewed 17 graduates from two online Master's programmes to explore their perceptions of how postgraduate study had influenced their practice and professional identity. Our thematic analysis produced three main themes (academic voice, infectious curiosity, and expanding worldview) which reflected changes in the participants' confidence, attitude, perspective, and agency across professional and academic settings. We then conducted a secondary phase of analysis using Bourdieu's concepts of 'field', 'capital', and 'habitus'. While graduate attributes have been conceptualised as the context-independent acquisition of traits that can be employed by individuals, Bourdieu's framework highlights their relational qualities: they are caught up in the cultural history and context of the student/professional, the reputation of the awarding institution, and the graduate's location within a network of professional peers.

Managing blood glucose during and after exercise in Type 1 diabetes: reproducibility of glucose response and a trial of a structured algorithm adjusting insulin and carbohydrate intake

AIMS AND OBJECTIVES

To enable people with Type 1 diabetes to exercise safely by investigating the reproducibility of the glucose response to an algorithm for carbohydrate and insulin adjustment during and after exercise compared to their self-management strategies.

BACKGROUND

Difficulties in managing blood glucose levels in Type 1 diabetes whilst exercising is known to deter people from exercise. Currently there is a limited evidence base to aid health care professionals enable people with diabetes to exercise safely. This study seeks to address this gap.

DESIGN

A quasi-experimental study was undertaken amongst people with Type 1 diabetes.

METHODS

Over 14 days, 14 participants undertook four exercise sessions (40 minutes at 50%VO2max). Two sessions were undertaken in week 1 self-managing their diabetes and two sessions in week 2 using an algorithm for carbohydrate and insulin adjustment.

RESULTS

The mean reduction of glucose levels detected by Continuous Glucose Monitoring during exercise was 3·1 (SD 2·03) mmol/l. Time spent within the range of 4-9 mmol/l during exercise was not significantly different between the self-managed and the algorithm weeks (-3-22·4 min). The mean reduction of blood glucose for each individual over all four exercise sessions ranged between 0·8-5·95 mmol/l. The technical error between days one and two was 2·4 mmol/l (CV=33·2%) and between days 3-4 the technical error was 2·7 mmol/l (CV=33·7%).

CONCLUSIONS

The results provide useful data about the reproducibility of the blood glucose response to moderate intensity exercise, despite the variability of individual responses 40 minutes of moderate intensity exercise decreases Continuous Glucose Monitoring glucose by 3 mmol/l with or without a 30% decrease of insulin before exercise.

RELEVANCE TO CLINICAL PRACTICE

This information provides valuable baseline information for people with diabetes and health care professionals who wish to encourage physical activity and undertake further research in this area.

Immune response to an 18-kilodalton outer membrane antigen identifies lipoprotein 20 as a Helicobacter pylori vaccine candidate

Experiments were performed using the standardized murine model of Helicobacter pylori infection to determine the immunogenicity of H. pylori outer membrane vesicles in immune protection. These vesicles, which are naturally shed from the surface of the bacterium, induce a protective response when administered intragastrically to mice in the presence of cholera holotoxin, despite the absence of the urease enzyme and associated Hsp54 chaperonin. Immunoblotting identified a specific serum immunoglobulin G (IgG) response to an 18-kDa outer membrane protein in a significant number of immunized animals. This commonly expressed, immunodominant protein was subsequently identified as lipoprotein 20 (Lpp20). Hybridoma backpacks secreting an IgG1 subclass monoclonal antibody to Lpp20 were generated in H. pylori-infected mice and were found to significantly reduce bacterial numbers, providing evidence that this surface-exposed antigen is a true vaccine candidate and not merely an antigenic marker for successful, protective immunization.

[Langerhans cell histiocytosis and myelomonocytic leukemia: a non-fortuitous association]

BACKGROUND

Langerhans cell histiocytosis is an uncommon clonal disorder. Its reactional or genetic nature is debated.

CASE REPORT

Three patients aged 71, 75 and 73 years with Langerhans cell histiocytosis also developed myelomoncytic leukemia (AML4, AML5, and chronic myelomonocytic leukemia). In two cases, there was no prior treatment which could potentially induce leukemia. In the third case, AML4 occurred shortly (10 months) after initiation of a vinblastin treatment.

DISCUSSION

This pathogenic association suggests a common origin for these two conditions, corresponding to an anomalous pluripotent stem cell line. These cases provide further evidence favoring the hypothesis of a genetic origin rather than a reactional origin for Langerhans cell histiocytosis.

Nutrition and diabetes: putting guidelines into practice

Dietary recommendations for the management of diabetes have changed over the past 10 years. There is now a reduced emphasis on the importance of carbohydrate in the diabetic diet. The first move away from carbohydrate restriction came in 1982 when the British Diabetic Association published its 'Dietary recommendations for diabetics for the 1980s'. This document suggested that the diet for people with diabetes should be based on a high intake of complex carbohydrate and fibre, with a restriction of fat intake. This article discusses the impact of these recommendations on different nutrients, and demonstrates, through the use of a case study, how these can be put into practice.

[Grover's acantholytic dermatosis (transient acantholytic dermatosis) (author's transl)]

The authors report two cases of Grover's transient acantholytic dermatosis. These two cases exhibit some unusual features. Case no. 1 is that of a 39-year-old female with typical lesions on chest, neck, back and upper limbs. The course was cyclic with spontaneous regressions. This condition had been present for 4 years. Case no. 2 was that of a 46-year-old man with a large erythemato-squamous plaque of the left chest wall exhibiting a vesicular lining. In both instances the histologic findings revealed a picture similar to that of Hailey-Hailey's familial benign pemphigus. In spite of these unusual data, long duration and atypical clinical aspects, these two cases are consistant with the diagnosis of Grover's disease as evidenced by description found in the literature.

[Anhidrosis. Presentation of an unusual case report]

A one month old girl with sudden attacks of fever and dehydration was found to have anhydrosis. Histologically the sweat glands were normal but the electrical resistance of the skin showed there was an abnormality of sweating. The cause of the disorder is unknown but could be due to a defect in the secretion of acetyl choline by the post ganglionic sympathetic nerves or due to a receptor defect in the sweat gland. This new syndrome should be considered in all infants with a high fever of unknown origin.

Familial and sporadic porphyria cutanea: two different diseases

Uroporphyrinogen (URO) decarboxylase was measured in hemoglobin-free erythrocytes from subjects with familial porphyria cutanea: the mean activity was about 50% of that found in erythrocytes from normal subjects. Asymptomatic carriers were always found in the family. No enzyme deficiency was found in erythrocytes from subjects with sporadic porphyria cutanea. The measurement of URO decarboxylase in erythrocytes seems to allow an easy distinction between these two groups of porphyria cutanea.