Authors:Justin Mausz; Walter Tavares Pages: 581 - 600 Abstract: Abstract The changing nature of healthcare education and delivery is such that clinicians will increasingly find themselves practicing in contexts that are physically and/or conceptually different from the settings in which they were trained, a practice that conflicts on some level with socio-cultural theories of learning that emphasize learning in context. Our objective was therefore to explore learning in ‘professionally distant’ contexts. Using paramedic education, where portions of training occur in hospital settings despite preparing students for out-of-hospital work, fifty-three informants (11 current students, 13 recent graduates, 16 paramedic program faculty and 13 program coordinators/directors) took part in five semi-structured focus groups. Participants reflected on the value and role of hospital placements in paramedic student development. All sessions were audio recorded, transcribed verbatim and analyzed using inductive thematic analysis. In this context six educational advantages and two challenges were identified when using professionally distant learning environments. Learning could still be associated with features such as (a) engagement through “authenticity”, (b) technical skill development, (c) interpersonal skill development, (d) psychological resilience, (e) healthcare system knowledge and (f) scaffolding. Variability in learning and misalignment with learning goals were identified as potential threats. Learning environments that are professionally distant from eventual practice settings may prove meaningful by providing learners with foundational and preparatory learning experiences for competencies that may be transferrable. This suggests that where learning occurs may be less important than how the experience contributes to the learner’s development and the meaning or value he/she derives from it. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9693-6 Issue No:Vol. 22, No. 3 (2017)
Authors:T. van Lankveld; J. Schoonenboom; R. A. Kusurkar; M. Volman; J. Beishuizen; G. Croiset Pages: 601 - 622 Abstract: Abstract Beginning medical teachers often see themselves as doctors or researchers rather than as teachers. Using both figured worlds theory and dialogical self theory, this study explores how beginning teachers in the field of undergraduate medical education integrate the teacher role into their identity. A qualitative study was performed, involving 18 beginning medical teachers at a Dutch medical school. The teachers were interviewed twice and kept a logbook over a period of 7 months. The study shows that the integration of the teacher role into the teachers’ identity was hampered by the idea that teaching is perceived by others as a low status occupation. Some teachers experienced significant tension because of this, while others showed resilience in resisting the negative associations that were thought to exist regarding teaching. The teachers used five different identity narratives in order to integrate the teacher role into their identity, in which the positions of teacher and doctor or researcher were found to be combined, adopted or rejected in diverse ways. The five identity narratives were: (1) coalition between the I-position of teacher and other I-positions; (2) no integration of the I-position of teacher: holding on to other I-positions; (3) construction of the I-position of teacher and other I-positions as opposites; (4) coalition between the I-position of teacher and a third position of coordinator; and (5) meta-position: trivialising the importance of status. These identity narratives offer starting points for supporting undergraduate teachers during their early professional years. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9694-5 Issue No:Vol. 22, No. 3 (2017)
Authors:Anna MacLeod; Olga Kits; Karen Mann; Jonathan Tummons; Keith W. Wilson Pages: 623 - 638 Abstract: Abstract Distributed medical education (DME) is becoming increasingly prevalent. Much of the published literature on DME has focused on the experiences of learners in distributed programs; however, our empirical work leads us to believe that DME changes the context significantly, not only for learners, but also for other important members of the educational community including audiovisual professionals, administrative professionals and faculty teachers. Based on a three-year ethnographic study, we provide a detailed account of how alliances between various workers involved in DME develop to produce and deliver an undergraduate medical curriculum across geographically separate campuses. We explore the question ‘What is the work involved in the delivery of a DME program'’ and cast a critical gaze on the essential but invisible, and therefore potentially unrecognized and underappreciated, contributions of AV professionals, administrative professionals, and faculty teachers. Our goal is to make visible the complexity of DME, including the essential contributions of these workers. The study was theoretically framed in sociomateriality and conceptually framed in Star and Strauss’ notion of articulation work. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9695-4 Issue No:Vol. 22, No. 3 (2017)
Authors:Debra Nestel; Jennifer Harlim; Melanie Bryant; Rajay Rampersad; David Hunter-Smith; Bob Spychal Pages: 639 - 651 Abstract: Abstract The landscape of surgical training is changing. The anticipated increase in the numbers of surgical trainees and the shift to competency-based surgical training places pressures on an already stretched health service. With these pressures in mind, we explored trainers’ and trainees’ experiences of surgical training in a less traditional rotation, an outer metropolitan hospital. We considered practice-based learning theories to make meaning of surgical training in this setting, in particular Actor–network theory. We adopted a qualitative approach and purposively sampled surgical trainers and trainees to participate in individual interviews and focus groups respectively. Transcripts were made and thematically analysed. Institutional human research ethics approval was obtained. Four surgical trainers and fourteen trainees participated. Almost without exception, participants’ report training needs to be well met. Emergent inter-related themes were: learning as social activity; learning and programmatic factors; learning and physical infrastructure; and, learning and organizational structure. This outer metropolitan hospital is suited to the provision of surgical training with the current rotational system for trainees. The setting offers experiences that enable consolidation of learning providing a rich and varied overall surgical training program. Although relational elements of learning were paramount they occurred within a complex environment. Actor–network theory was used to give meaning to emergent themes acknowledging that actors (both people and objects) and their interactions combine to influence training quality, shifting the focus of responsibility for learning away from individuals to the complex interactions in which they work and learn. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9697-2 Issue No:Vol. 22, No. 3 (2017)
Authors:Anna K. Vnuk; Andy Wearn; Charlotte E. Rees Pages: 653 - 665 Abstract: Abstract Peer Physical Examination (PPE) is an educational tool used globally for learning early clinical skills and anatomy. In quantitative research, there are differences in students’ preferences and actual participation in PPE by gender. This novel study qualitatively explores the effect that gender has on medical students’ experiences of learning physical examination through PPE. We employ an interpretative approach to uncover the PPE experiences of students from a European, graduate-entry medical school. Volunteers participated in either individual or group interviews. The data were transcribed, de-identified and analysed using thematic analysis. There was evidence of gender inequity in PPE, with students describing significant imbalances in participation. Male students adopted roles that generated significant personal discomfort and led to fewer experiences as examiners. Assumptions were made by tutors and students about gender roles: male students’ ready acceptance of exposure to be examined and female students’ need to be protected from particular examinations. In contrast with the first assumption, male students did feel coerced or obliged to be examined. Students described their experiences of taking action to break down the gender barrier. Importantly, students reported that tutors played a role in perpetuating inequities. These findings, whilst relating to one university, have implications for all settings where PPE is used. Educators should be vigilant about gender issues and the effect that they may have on students’ participation in PPE to ensure that students are not disadvantaged in their learning. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9699-0 Issue No:Vol. 22, No. 3 (2017)
Authors:Michelle McLean Pages: 667 - 689 Abstract: Abstract Using interpretative phenomenological analysis to make meaning of the experiences of three highly qualified registered nurses who had enrolled in an undergraduate medical programme, this study provides insight into their personal journeys of wanting to become ‘different’ doctors. In so doing, they conceptualised their future selves as adding clinical reasoning and diagnostic skills to the patient-centred caring ethic of their nursing practice, becoming a multi-skilled community member or helping to fix the health care culture. By customising their identities, e.g. by splinting (aligning with their stronger nursing identity), by enriching current nursing practice with newly acquired theory as medical students or by patching a perceived deficiency (i.e. patient-centredness) in medicine, they tailored their identities. Their journeys had, however, not been the natural progression they had anticipated, threatened by perceived and/or real intrinsic (e.g. working as nurses whilst studying medicine) and extrinsic (e.g. interprofessional rivalry) factors. Rather than being accepted as legitimate newcomers to the medical profession, the women sometimes felt like intruders. Some nursing colleagues accused them of desertion. In response, they generally withheld their identities as nurses or medical students, compartmentalising their group membership. This study has highlighted the role of personal (e.g. prior experience; agency; resilience; personality) and contextual factors in ‘becoming’ a doctor. A recommendation emerging from this study is the need for interprofessional learning in the medical curriculum to cultivate a health care culture of collaboration rather than competition. Future research is required in terms of how allied health professionals transition to medicine. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9700-y Issue No:Vol. 22, No. 3 (2017)
Authors:Salina Juma; Mark Goldszmidt Pages: 691 - 711 Abstract: Abstract Research suggests that physicians perform multiple reasoning tasks beyond diagnosis during patient review. However, these remain largely theoretical. The purpose of this study was to explore reasoning tasks in clinical practice during patient admission review. The authors used a constant comparative approach—an iterative and inductive process of coding and recoding—to analyze transcripts from 38 audio-recorded case reviews between junior trainees and their senior residents or attendings. Using a previous list of reasoning tasks, analysis focused on what tasks were performed, when they occurred, and how they related to the other tasks. All 24 tasks were observed in at least one review with a mean of 17.9 (Min = 15, Max = 22) distinct tasks per review. Two new tasks—assess illness severity and patient decision-making capacity—were identified, thus 26 tasks were examined. Three overarching tasks were identified—assess priorities, determine and refine the most likely diagnosis and establish and refine management plans—that occurred throughout all stages of the case review starting from patient identification and continuing through to assessment and plan. A fourth possible overarching task—reflection—was also identified but only observed in four instances across three cases. The other 22 tasks appeared to be context dependent serving to support, expand, and refine one or more overarching tasks. Tasks were non-sequential and the same supporting task could serve more than one overarching task. The authors conclude that these findings provide insight into the ‘what’ and ‘when’ of physician reasoning during case review that can be used to support professional development, clinical training and patient care. In particular, they draw attention to the iterative way in which each task is addressed during a case review and how this finding may challenge conventional ways of teaching and assessing clinical communication and reasoning. They also suggest that further research is needed to explore how physicians decide why a supporting task is required in a particular context. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9701-x Issue No:Vol. 22, No. 3 (2017)
Authors:Lyn Li Lean; Ryan Yee Shiun Hong; Lian Kah Ti Pages: 713 - 721 Abstract: Abstract Communication of feedback during teaching of practical procedures is a fine balance of structure and timing. We investigate if continuous in-task (IT) or end-task feedback (ET) is more effective in teaching spinal anaesthesia to medical students. End-task feedback was hypothesized to improve both short-term and long-term procedural learning retention as experiential learning promotes active learning after encountering errors during practice. Upon exposure to a 5-min instructional video, students randomized to IT or ET feedbacks were trained using a spinal simulator mannequin. A blinded expert tested the students using a spinal anaesthesia checklist in the short term (immediate) and long-term (average 4 months). Sixty-five students completed the training and testing. There were no differences in demographics of age or gender within IT or ET distributions. Both short-term and long-term learning retention of spinal anaesthesia ET feedback proved to be better (P < 0.01) than IT feedback. The time taken for ET students was shorter at long-term testing. End-task feedback improves both short-term and long-term procedural learning retention. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9703-8 Issue No:Vol. 22, No. 3 (2017)
Authors:Kayley Lyons; Jacqueline E. McLaughlin; Julia Khanova; Mary T. Roth Pages: 723 - 739 Abstract: Abstract Cognitive apprenticeship theory emphasizes the process of making expert thinking “visible” to students and fostering the cognitive and meta-cognitive processes required for expertise. The purpose of this review was to evaluate the use of cognitive apprenticeship theory with the primary aim of understanding how and to what extent the theory has been applied to the design, implementation, and analysis of education in the health sciences. The initial search yielded 149 articles, with 45 excluded because they contained the term “cognitive apprenticeship” only in reference list. The remaining 104 articles were categorized using a theory talk coding scheme. An in depth qualitative synthesis and review was conducted for the 26 articles falling into the major theory talk category. Application of cognitive apprenticeship theory tended to focus on the methods dimension (e.g., coaching, mentoring, scaffolding), with some consideration for the content and sociology dimensions. Cognitive apprenticeship was applied in various disciplines (e.g., nursing, medicine, veterinary) and educational settings (e.g., clinical, simulations, online). Health sciences education researchers often used cognitive apprenticeship to inform instructional design and instrument development. Major recommendations from the literature included consideration for contextual influences, providing faculty development, and expanding application of the theory to improve instructional design and student outcomes. This body of research provides critical insight into cognitive apprenticeship theory and extends our understanding of how to develop expert thinking in health sciences students. New research directions should apply the theory into additional aspects of health sciences educational research, such as classroom learning and interprofessional education. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9707-4 Issue No:Vol. 22, No. 3 (2017)
Authors:Martin V. Pusic; Kathy Boutis; Martin R. Pecaric; Oleksander Savenkov; Jason W. Beckstead; Mohamad Y. Jaber Pages: 741 - 759 Abstract: Abstract Learning curves are a useful way of representing the rate of learning over time. Features include an index of baseline performance (y-intercept), the efficiency of learning over time (slope parameter) and the maximal theoretical performance achievable (upper asymptote). Each of these parameters can be statistically modelled on an individual and group basis with the resulting estimates being useful to both learners and educators for feedback and educational quality improvement. In this primer, we review various descriptive and modelling techniques appropriate to learning curves including smoothing, regression modelling and application of the Thurstone model. Using an example dataset we demonstrate each technique as it specifically applies to learning curves and point out limitations. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9709-2 Issue No:Vol. 22, No. 3 (2017)
Authors:Malika Sharma; Ayelet Kuper Pages: 761 - 764 Abstract: Abstract The deaths of black men and women while in police custody, rising anti-immigrant sentiment and rhetoric in high-income countries, and the continued health disparities experienced by Indigenous communities globally have brought race and racism to the forefront of public discourse in recent years. In a context where academic health science centres are increasingly called to be “socially accountable,” ignoring the larger social context of race and racism is something that medical education institutions can little afford to do. However, many such institutions have largely remained silent on the issue of race and racism, both within and outside of healthcare. Most medical education continues to emphasize a primarily biological understanding of race. We argue that a different approach is needed. Highlighting the social construction of race is an essential starting point for educators and trainees to tackle racialized health disparities in our clinics and to challenge racism in our classrooms, educational and research institutions, and communities. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9732-3 Issue No:Vol. 22, No. 3 (2017)
Authors:A. van der Gijp; C. J. Ravesloot; H. Jarodzka; M. F. van der Schaaf; I. C. van der Schaaf; J. P. J. van Schaik; Th. J. ten Cate Pages: 765 - 787 Abstract: Abstract Eye tracking research has been conducted for decades to gain understanding of visual diagnosis such as in radiology. For educational purposes, it is important to identify visual search patterns that are related to high perceptual performance and to identify effective teaching strategies. This review of eye-tracking literature in the radiology domain aims to identify visual search patterns associated with high perceptual performance. Databases PubMed, EMBASE, ERIC, PsycINFO, Scopus and Web of Science were searched using ‘visual perception’ OR ‘eye tracking’ AND ‘radiology’ and synonyms. Two authors independently screened search results and included eye tracking studies concerning visual skills in radiology published between January 1, 1994 and July 31, 2015. Two authors independently assessed study quality with the Medical Education Research Study Quality Instrument, and extracted study data with respect to design, participant and task characteristics, and variables. A thematic analysis was conducted to extract and arrange study results, and a textual narrative synthesis was applied for data integration and interpretation. The search resulted in 22 relevant full-text articles. Thematic analysis resulted in six themes that informed the relation between visual search and level of expertise: (1) time on task, (2) eye movement characteristics of experts, (3) differences in visual attention, (4) visual search patterns, (5) search patterns in cross sectional stack imaging, and (6) teaching visual search strategies. Expert search was found to be characterized by a global-focal search pattern, which represents an initial global impression, followed by a detailed, focal search-to-find mode. Specific task-related search patterns, like drilling through CT scans and systematic search in chest X-rays, were found to be related to high expert levels. One study investigated teaching of visual search strategies, and did not find a significant effect on perceptual performance. Eye tracking literature in radiology indicates several search patterns are related to high levels of expertise, but teaching novices to search as an expert may not be effective. Experimental research is needed to find out which search strategies can improve image perception in learners. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9698-1 Issue No:Vol. 22, No. 3 (2017)
Authors:Ronald Cusano; Kevin Busche; Sylvain Coderre; Wayne Woloschuk; Karen Chadbolt; Kevin McLaughlin Pages: 789 - 796 Abstract: Abstract Despite the fact that the length of medical school training has remained stable for many years, the expectations of graduating medical students (and the schools that train them) continue to increase. In this Reflection, the authors discuss motives for educational inflation and suggest that these are likely innocent, well-intentioned, and subconscious—and include both a propensity to increase expectations of ourselves and others over time, and a reluctance to reduce training content and expectations. They then discuss potential risks of educational inflation, including reduced emphasis on core knowledge and clinical skills, and adverse effects on the emotional, psychological, and financial wellbeing of students. While acknowledging the need to change curricula to improve learning and clinical outcomes, the authors proffer that it is naïve to assume that we can inflate educational expectations at no additional cost. They suggest that before implementing and/or mandating change, we should consider of all the costs that medical schools and students might incur, including opportunity costs and the impact on the emotional and financial wellbeing of students. They propose a cost-effectiveness framework for medical education and advocate prioritization of interventions that improve learning outcomes with no additional costs or are cost-saving without adversely impacting learning outcomes. When there is an additional cost for improved learning outcomes or a decline in learning outcomes as a result of cost saving interventions, they suggest careful consideration and justification of this trade-off. And when there are neither improved learning outcomes nor cost savings they recommend resisting the urge to change. PubDate: 2017-08-01 DOI: 10.1007/s10459-016-9708-3 Issue No:Vol. 22, No. 3 (2017)
Authors:Eunbae B. Yang; Myung Ae Lee; Yoon Soo Park Abstract: Abstract In 2012, the National Health Personnel Licensing Examination Board of Korea decided to publicly disclose all test items and answers to satisfy the test takers’ right to know and enhance the transparency of tests administered by the government. This study investigated the effects of item disclosure on the medical licensing examination (MLE), examining test taker performance, psychometric characteristics, and factors affecting pass rates. This paper analyzed examinee performance data (n = 20,455) from 41 medical schools who took the MLE before (2009–2011) and after (2012–2014) the item disclosure policy (5548 total items). Changes in passing rates, performance of examinee, difficulty and reliability of the test, and factors affecting pass rate of the medical licensing examination before and after item disclosure were analyzed. In order to identify changes caused by item disclosure in the effects of student and school variables on the passing rate of MLE, Binary Logistic Hierarchical Linear Model was used. There was no significant change in pass rates before and after item disclosure. There was a modest increase in the proportion of test takers in the high-scoring group, following item disclosure. Degree completion status, gender, age of applicants and school mean were significant factors affecting pass rates, regardless of item disclosure. There was no difference between passing rates before and after item disclosure with respect to student- and school-level variables. Despite potential concerns for changes in test and examinee characteristics, empirical findings indicate that there was no significant difference caused by implementing item disclosure. PubDate: 2017-07-31 DOI: 10.1007/s10459-017-9788-8
Authors:Jacob Pearce Abstract: Abstract Practitioners in health sciences education and assessment regularly use a range of psychometric techniques to analyse data, evaluate models, and make crucial progression decisions regarding student learning. However, a recent editorial entitled “Is Psychometrics Science” highlighted some core epistemological and practical problems in psychometrics, and brought its legitimacy into question. This paper attempts to address these issues by applying some key ideas from history and philosophy of science (HPS) discourse. I present some of the conceptual developments in HPS that have bearing on the psychometrics debate. Next, by shifting the focus onto what constitutes the practice of science, I discuss psychometrics in action. Some incorrectly conceptualize science as an assemblage of truths, rather than an assemblage of tools and goals. Psychometrics, however, seems to be an assemblage of methods and techniques. Psychometrics in action represents a range of practices using specific tools in specific contexts. This does not render the practice of psychometrics meaningless or futile. Engaging in debates about whether or not we should regard psychometrics as ‘scientific’ is, however, a fruitless enterprise. The key question and focus should be whether, on what grounds, and in what contexts, the existing methods and techniques used by psychometricians can be justified or criticized. PubDate: 2017-07-27 DOI: 10.1007/s10459-017-9789-7
Authors:Pam Hruska; Kent G. Hecker; Sylvain Coderre; Kevin McLaughlin; Filomeno Cortese; Christopher Doig; Tanya Beran; Bruce Wright; Olav Krigolson PubDate: 2017-07-25 DOI: 10.1007/s10459-017-9787-9
Authors:Pam Hruska; Olav Krigolson; Sylvain Coderre; Kevin McLaughlin; Filomeno Cortese; Christopher Doig; Tanya Beran; Bruce Wright; Kent G. Hecker PubDate: 2017-07-25 DOI: 10.1007/s10459-017-9786-x
Authors:Michael Paget; Gurbir Brar; Pamela Veale; Kevin Busche; Sylvain Coderre; Wayne Woloschuk; Kevin McLaughlin Abstract: Abstract Prior studies have shown a correlation between the grades students receive and how they rate their teacher in the classroom. In this study, the authors probe this association on clinical rotations and explore potential mechanisms. All In-Training Evaluation Reports (ITERs) for students on mandatory clerkship rotations from April 1, 2013 to January 31, 2015 were matched with the corresponding student’s rating of their teacher (SRT). The date and time that ITERs and SRTs were submitted was used to divide SRTs into those submitted before versus after the corresponding ITER was submitted. Multilevel, mixed effects linear regression was used to examine the association between SRT, ITER rating, and whether the ITER was submitted before or after SRT. Of 2373 paired evaluations, 1098 (46.3%) SRT were submitted before the teacher had submitted the ITER. There was a significant interaction between explanatory variables: when ITER ratings had not yet been submitted, the regression coefficient for this association was 0.25 (95% confidence interval [0.17, 0.33], p < 0.001), whereas the regression coefficient was significantly higher when ITER ratings were submitted prior to SRT (0.40 [0.31, 0.49], p < 0.001). Finding an association between SRT and ITER when students do not know their ITER ratings suggests that SRTs can capture attributes of effective teaching, but the effect modification when students have access to their ITER rating supports grade satisfaction bias. Further studies are needed to explain the mechanism of grade satisfaction and to identify other biases that may impact the validity of SRT. PubDate: 2017-07-13 DOI: 10.1007/s10459-017-9783-0
Authors:Claudio Violato; Hong Gao; Mary Claire O’Brien; David Grier; E Shen Abstract: Abstract The distinction between basic sciences and clinical knowledge which has led to a theoretical debate on how medical expertise is developed has implications for medical school and lifelong medical education. This longitudinal, population based observational study was conducted to test the fit of three theories—knowledge encapsulation, independent influence, distinct domains—of the development of medical expertise employing structural equation modelling. Data were collected from 548 physicians (292 men—53.3%; 256 women—46.7%; mean age = 24.2 years on admission) who had graduated from medical school 2009–2014. They included (1) Admissions data of undergraduate grade point average and Medical College Admission Test sub-test scores, (2) Course performance data from years 1, 2, and 3 of medical school, and (3) Performance on the NBME exams (i.e., Step 1, Step 2 CK, and Step 3). Statistical fit indices (Goodness of Fit Index—GFI; standardized root mean squared residual—SRMR; root mean squared error of approximation—RSMEA) and comparative fit \((X_{D}^{2} ,X^{2} )\) of three theories of cognitive development of medical expertise were used to assess model fit. There is support for the knowledge encapsulation three factor model of clinical competency (GFI = 0.973, SRMR = 0.043, RSMEA = 0.063) which had superior fit indices to both the independent influence and distinct domains theories ( \(X_{29}^{2} = 88.11\) vs \(X_{29}^{2} = 443.91\) [ \(X_{D}^{2} = 355.80\) ] vs \(X_{29}^{2} = 514.93\) [ \(X_{D}^{2} = 426.82\) ], respectively). The findings support a theory where basic sciences and medical aptitude are direct, correlated influences on clinical competency that encapsulates basic knowledge. PubDate: 2017-07-12 DOI: 10.1007/s10459-017-9784-z
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