Authors:Shannon Fong; Amy Tan; Joanna Czupryn; Anna Oswald Pages: 15 - 32 Abstract: The use of patient educators is one of many teaching strategies meant to foster principles of patient-centred care. We previously found that early patient educator exposure helped to shape the understanding of patient-centredness in pre-clerkship learners. We now expand on this work to evaluate whether there is persistence of initial perceptions and to explore general reflections on longer-term impacts of early patient educator exposures once learners are immersed in the clinical phase of their training. In this follow-up study, we conducted group interviews with a sample of learners who wrote reflections as part of their pre-clerkship patient educator experience. We explored how perspectives on patient educators changed over time, and determined which themes identified during pre-clerkship remained relevant to clinical trainees. Audio recordings were transcribed and analyzed thematically using a hybrid inductive and deductive analysis to construct a thematic framework derived through a method of constant comparison. We identified three new themes: “value of early clinical experience”, “change in learners’ perspectives”, and “valuing and applying CanMEDS roles other than Medical Expert”. Themes from pre-clerkship that remained relevant included: “patients’ perspective humanizes disease”, “patients’ experiences with navigating the healthcare system”, “learners’ perceptions of the learning strategy”, and “inaccuracies and inconsistencies in the learning experience.” Many themes identified in pre-clerkship learners remain relevant in early clinical trainees. Further, insights from pre-clerkship experiences with patient educators evolve as learners experience clerkship with definite shifts in emphasis and new perspectives. This work illuminates the utility of patient educators for those considering this strategy for supporting the development of patient-centredness in undergraduate medical education. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9845-y Issue No:Vol. 24, No. 1 (2019)
Authors:Barbara Griffin; Jaime Auton; Robbert Duvivier; Boaz Shulruf; Wendy Hu Pages: 33 - 43 Abstract: This study compared the profile of those who, after initial failure to be selected, choose to reapply to study medicine with those who did not reapply. It also evaluates the chance of a successful outcome for re-applicants. In 2013, 4007 applicants to undergraduate medical schools in the largest state in Australia were unsuccessful. Those who chose to reapply (n = 665) were compared to those who did not reapply (n = 3342). Results showed that the odds of re-applying to medicine were 55% less for those from rural areas, and 39% more for those from academically-selective schools. Those who had higher cognitive ability and high school academic performance scores in 2013 were also more likely to re-apply. Socioeconomic status was not related to re-application choice. Re-applicants’ showed significant improvements in selection test scores and had a 34% greater probability of selection than first-time applicants who were also interviewed in the same selection round. The findings of this study indicate that re-testing and re-application improves one’s chance of selection into an undergraduate medical degree, but may further reduce the diversity of medical student cohorts in terms of rural background and educational background. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9847-9 Issue No:Vol. 24, No. 1 (2019)
Authors:Rose Hatala; Jacqueline Gutman; Matthew Lineberry; Marc Triola; Martin Pusic Pages: 45 - 63 Abstract: Learning curves can support a competency-based approach to assessment for learning. When interpreting repeated assessment data displayed as learning curves, a key assessment question is: “How well is each learner learning'” We outline the validity argument and investigation relevant to this question, for a computer-based repeated assessment of competence in electrocardiogram (ECG) interpretation. We developed an on-line ECG learning program based on 292 anonymized ECGs collected from an electronic patient database. After diagnosing each ECG, participants received feedback including the computer interpretation, cardiologist’s annotation, and correct diagnosis. In 2015, participants from a single institution, across a range of ECG skill levels, diagnosed at least 60 ECGs. We planned, collected and evaluated validity evidence under each inference of Kane’s validity framework. For Scoring, three cardiologists’ kappa for agreement on correct diagnosis was 0.92. There was a range of ECG difficulty across and within each diagnostic category. For Generalization, appropriate sampling was reflected in the inclusion of a typical clinical base rate of 39% normal ECGs. Applying generalizability theory presented unique challenges. Under the Extrapolation inference, group learning curves demonstrated expert–novice differences, performance increased with practice and the incremental phase of the learning curve reflected ongoing, effortful learning. A minority of learners had atypical learning curves. We did not collect Implications evidence. Our results support a preliminary validity argument for a learning curve assessment approach for repeated ECG interpretation with deliberate and mixed practice. This approach holds promise for providing educators and researchers, in collaboration with their learners, with deeper insights into how well each learner is learning. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9846-x Issue No:Vol. 24, No. 1 (2019)
Authors:Shalote Chipamaunga; Detlef Prozesky Pages: 65 - 84 Abstract: The merits of integrative learning in promoting better educational outcomes are not questionable. However, there are contentious views on how to implement it. In addition, there is scanty evidence on how students experience it and how they develop the ability to integrate learning. In this paper, students’ experiences of integration are explored. Using a phenomenographic approach, in-depth interviews and focus group discussions were conducted with students and teachers in an undergraduate medical programme. Analysis of data revealed the “outcome space”—a collective of students’ experiences. Using the “anatomy of awareness” framework, the experiences were structured according to how students experience the meaning of integration of learning; the abilities that they perceive are needed to carry it out; the acts of learning that for them are associated with these abilities; and internal and external factors which they perceive to facilitate or hinder it. The research revealed five conceptions of integration and abilities to achieve it, developing with increasing sophistication over time. Teachers’ experiences with the curriculum generally supported the students’ experiences. To facilitate integrative learning, starting earlier in the programme, intentional contextually directed interventions are suggested. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9850-1 Issue No:Vol. 24, No. 1 (2019)
Authors:Victor Lee; Keira Brain; Jenepher Martin Pages: 85 - 102 Abstract: The increasing use of direct observation tools to assess routine performance has resulted in the growing reliance on assessor-based judgements in the workplace. However, we have a limited understanding of how assessors make judgements and formulate ratings in real world contexts. The current research on assessor cognition has largely focused on the cognitive domain but the contextual factors are equally important, and both are closely interconnected. This study aimed to explore the perceived cognitive and contextual factors influencing Mini-CEX assessor judgements in the Emergency Department setting. We used a conceptual framework of assessor-based judgement to develop a sequential mixed methods study. We analysed and integrated survey and focus group results to illustrate self-reported cognitive and contextual factors influencing assessor judgements. We used situated cognition theory as a sensitizing lens to explore the interactions between people and their environment. The major factors highlighted through our mixed methods study were: clarity of the assessment, reliance on and variable approach to overall impression (gestalt), role tension especially when giving constructive feedback, prior knowledge of the trainee and case complexity. We identified prevailing tensions between participants (assessors and trainees), interactions (assessment and feedback) and setting. The two practical implications of our research are the need to broaden assessor training to incorporate both cognitive and contextual domains, and the need to develop a more holistic understanding of assessor-based judgements in real world contexts to better inform future research and development in workplace-based assessments. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9851-0 Issue No:Vol. 24, No. 1 (2019)
Authors:Umberin Najeeb; Brian Wong; Elisa Hollenberg; Lynfa Stroud; Susan Edwards; Ayelet Kuper Pages: 103 - 123 Abstract: Many international medical graduates (IMGs) enter North American residency programs every year. The Canadian IMG physician pool increasingly includes Canadian-born IMGs (C-IMGs) along with Immigrant-IMGs (I-IMGs). Similar trends exist in the United States. Our objective was to understand the similarities and differences in the challenges faced by both I-IMGs and C-IMGs during residency to identify actionable recommendations to support them during this critical time. We performed a multiple case study of IMGs’ experiences at a large Canadian university. Within our two descriptive cases (I-IMGs, C-IMGs) we iteratively conducted twenty-two semi-structured interviews; we thematically analyzed our data within, between, and across both cases to understand challenges to IMGs’ integration and opportunities for curricular innovations to facilitate their adaptation process. Research team members with different perspectives contributed reflexively to the thematic analysis. Participants identified key differences between medical culture and knowledge expected in Canada and the health systems and curricula in which they originally trained. I-IMG and C-IMG participants perceived two major challenges: discrimination because of negative labelling as IMGs and difficulties navigating their initial residency months. C-IMGs described a third challenge: frustration around the focus on the needs of I-IMGs. Participants from both groups identified two major opportunities: their desire to help other IMGs and a need for mentorship. I-IMGs and C-IMGs face diverse challenges during their training, including disorientation and discrimination. We identified specific objectives to inform the design of curriculum and support services that residency programs can offer trainees as well as important targets for resident education and faculty development. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9852-z Issue No:Vol. 24, No. 1 (2019)
Authors:Agnes Elmberger; Erik Björck; Matilda Liljedahl; Juha Nieminen; Klara Bolander Laksov Pages: 125 - 140 Abstract: Many medical universities offer educational development activities to support clinical teachers in their teaching role. Research has focused on the scope and effectiveness of such activities and on why individual teachers attend. However, systemic perspectives that go beyond a focus on individual participants are scarce in the existing literature. Employing activity theory, we explored how clinical teachers’ engagement in educational development was affected by the systems they act within. Three focus groups were held with clinical teachers from different professions. A thematic analysis was used to map the contradictions between the systems that the participants were part of and the manifestations of these contradictions in the system of education. In our model, clinical teachers were part of three activity systems directed by the objects of patient care, research and education respectively. Contradictions arose between these systems as their objects were not aligned. This manifested through the enacted values of the academic hospital, difficulties establishing educational discussions in the clinical workplace, the transient nature of educational employments, and impediments to developing a teacher identity. These findings offer insights into the complexities of engaging in educational development as clinical teachers’ priorities interact with the practices and values of the academic hospital, suggesting that attention needs to shift from individual teachers to developing the systems in which they work. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9853-y Issue No:Vol. 24, No. 1 (2019)
Authors:Mark R. Raymond; Craig Stevens; S. Deniz Bucak Pages: 141 - 150 Abstract: Research suggests that the three-option format is optimal for multiple choice questions (MCQs). This conclusion is supported by numerous studies showing that most distractors (i.e., incorrect answers) are selected by so few examinees that they are essentially nonfunctional. However, nearly all studies have defined a distractor as nonfunctional if it is selected by fewer than 5% of examinees. A limitation of this definition is that the proportion of examinees available to choose a distractor depends on overall item difficulty. This is especially problematic for mastery tests, which consist of items that most examinees are expected to answer correctly. Based on the traditional definition of nonfunctional, a five-option MCQ answered correctly by greater than 90% of examinees will be constrained to have only one functional distractor. The primary purpose of the present study was to evaluate an index of nonfunctional that is sensitive to item difficulty. A secondary purpose was to extend previous research by studying distractor functionality within the context of professionally-developed credentialing tests. Data were analyzed for 840 MCQs consisting of five options per item. Results based on the traditional definition of nonfunctional were consistent with previous research indicating that most MCQs had one or two functional distractors. In contrast, the newly proposed index indicated that nearly half (47.3%) of all items had three or four functional distractors. Implications for item and test development are discussed. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9855-9 Issue No:Vol. 24, No. 1 (2019)
Authors:Marjolein Versteeg; Floris M. van Blankenstein; Hein Putter; Paul Steendijk Pages: 151 - 165 Abstract: Comprehension of physiology is essential for development of clinical reasoning. However, medical students often struggle to understand physiological concepts. Interactive learning through Peer instruction (PI) is known to stimulate students’ comprehension, but its relative efficacy and working mechanisms remain to be elucidated. In this study, we investigated if and how PI could optimize comprehension of physiological concepts and transfer relative to Self-explanation (SE) which is considered a lower-order type of overt learning. First-year medical students (n = 317) were randomly assigned to either PI or SE in a pre-post test design, followed by a set of near and far transfer questions. In both PI and SE groups post-test scores were significantly improved (p < 0.0001) with PI outperforming SE (+ 35% vs. + 23%, p = 0.006). Interestingly, a substantial number of students with initial incorrect answers even had enhanced scores after discussion with an incorrect peer. Both methods showed higher transfer scores than control (p = 0.006), with a tendency for higher near transfer scores for PI. These findings support PI as a valuable method to enhance comprehension of physiological concepts. Moreover, by comparing the effects of interactive PI with constructive SE we have established new insights that complement educational theories on overt learning activities. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9858-6 Issue No:Vol. 24, No. 1 (2019)
Authors:Carrie B. Jackson; Laurel A. Brabson; Lauren B. Quetsch; Amy D. Herschell Pages: 167 - 183 Abstract: Consistent with Baldwin and Ford’s model (Pers Psychol 41(1):63–105, 1988), training transfer is defined as the generalization of learning from a training to everyday practice in the workplace. The purpose of this review was to examine the influence of work-environment factors, one component of the model hypothesized to influence training transfer within behavioral health. An electronic literature search guided by the Consolidated Framework for Implementation Research’s inner setting domain was conducted was conducted on Medline OVID, Medline EMBASE, and PsycINFO databases. Of 9184 unique articles, 169 full-text versions of articles were screened for eligibility, yielding 26 articles meeting inclusion criteria. Results from the 26 studies revealed that overall, having more positive networks and communication, culture, implementation climate, and readiness for implementation can facilitate training transfer. Although few studies have examined the impact of inner setting factors on training transfer, these results suggest organizational context is important to consider with training efforts. These findings have important implications for individuals in the broader health professions educational field. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9837-y Issue No:Vol. 24, No. 1 (2019)
Authors:Jochanan Benbassat Pages: 185 - 194 Abstract: Undergraduate clinical education follows the “bedside” tradition that exposes students to inpatients. However, the hospital learning environment has two main limitations. First, most inpatients require acute care, and students may complete their training without seeing patients with frequent non-emergent and chronic diseases that are managed in outpatient settings. Second, students rarely cope with diagnostic problems, because most inpatients are diagnosed in the community or the emergency room. These limitations have led some medical schools to offer longitudinal integrated clerkships in community settings instead of hospital block clerkship rotations. In this paper, I propose the hypothesis that the hospital learning environment has a third limitation: it causes students’ distress and delays their development of reflectivity and medical professionalism. This hypothesis is supported by evidence that (a) the clinical learning environment, rather than students’ personality traits, is the major driver of students’ distress, and (b) the development of attributes, such as moral reasoning, empathy, emotional intelligence and tolerance of uncertainty that are included in the definitions of both reflectivity and medical professionalism, is arrested during undergraduate medical training. Future research may test the proposed hypothesis by comparing students’ development of these attributes during clerkships in hospital wards with that during longitudinal clerkships in community settings. PubDate: 2019-03-01 DOI: 10.1007/s10459-018-9818-1 Issue No:Vol. 24, No. 1 (2019)
Authors:Ying Yun Juliana Koh; Jerome I. Rotgans; Preman Rajalingam; Paul Gagnon; Naomi Low-Beer; Henk G. Schmidt Abstract: Pre-class preparation is a crucial component of team-based learning (TBL). Lack of preparation hinders both individual learning and team performance during TBL. The purpose of the present study was to explore how the grading of the individual readiness assurance test (iRAT) can affect pre-class preparation, iRAT performance and performance in the end-of-year examination. Using a quasi-experimental design, Year 1 and 2 students’ download frequency for their pre-class materials, performance on iRAT and examination were examined under two conditions; (1) under which the iRAT was graded and (2) under which the iRAT was ungraded. Medical students (N = 220) from three cohorts were included in the study. Differences between both conditions were tested by means of six separate ANCOVAs, using medical school entry test scores as the covariate to account for potential cohort effects. Results revealed that students were downloading more pre-class materials prior to their TBL sessions, and were performed significantly better on iRAT when their performance was graded, even after controlling for cohort effects. Analysis of covariance demonstrated that performance on iRAT also appeared to affect performance on their examination scores. The results of the study suggest that grading has a positive effect on students’ iRAT scores. Implications for TBL are discussed. PubDate: 2019-02-06 DOI: 10.1007/s10459-019-09878-5
Authors:Antoon Cox; Shuangyu Li Abstract: The well-structured medical communication models that are typically described in textbooks are relevant to practice, but the actual messy interactional realities of consultations are often a far cry away from them. As a result, medical trainees frequently encounter difficulties when applying communication skills acquired during training to medical practice. This paper reflects on how clinical communication research and courses can incorporate the growing need for context-bound communication skills training. This paper illustrates how concepts from the research field of language and social interaction can facilitate the description and analysis of communication in clinical encounters, drawing on a real-life example from an increasingly common clinical scenario: a consultation in the emergency department involving a patient who does not speak the same language as the clinician. The proposed way of looking at clinical communication can enrich clinical skills training as it provides a tool to study, analyze, visualize and discuss communication from a different perspective that simultaneously accounts for interactional and clinical reasoning aspects of medical consultations. PubDate: 2019-02-04 DOI: 10.1007/s10459-018-09873-2
Authors:Matt Sibbald; Jonathan Sherbino; Jonathan S. Ilgen; Laura Zwaan; Sarah Blissett; Sandra Monteiro; Geoffrey Norman Abstract: There is an ongoing debate regarding the cause of diagnostic errors. One view is that errors result from unconscious application of cognitive heuristics; the alternative is that errors are a consequence of knowledge deficits. The objective of this study was to compare the effectiveness of checklists that (a) identify and address cognitive biases or (b) promote knowledge retrieval, as a means to reduce errors in ECG interpretation. Novice postgraduate year (PGY) 1 emergency medicine and internal medicine residents (n = 40) and experienced cardiology fellows (PGY 4–6) (n = 21) were randomly allocated to three conditions: a debiasing checklist, a content (knowledge) checklist, or control (no checklist) to be used while interpreting 20 ECGs. Half of the ECGs were deliberately engineered to predispose to bias. Diagnostic performance under either checklist intervention was not significantly better than the control. As expected, more errors occurred when cases were designed to induce bias (F = 96.9, p < 0.0001). There was no significant interaction between the instructional condition and level of learner. Checklists attempting to help learners identify cognitive bias or mobilize domain-specific knowledge did not have an overall effect in reducing diagnostic errors in ECG interpretation, although they may help novices. Even when cognitive biases are deliberately inserted in cases, cognitive debiasing checklists did not improve participants’ performance. PubDate: 2019-01-29 DOI: 10.1007/s10459-019-09875-8
Authors:Eugène J. F. M. Custers Abstract: In this paper, we will first discuss two current meta-theories dealing with different, aspects of “truth”. The first metatheory conceives of truth in terms of coherence (rationality, consistency): a body of knowledge is true when it contains no inconsistencies and has at least some credibility. The second metatheory conceives of truth as correspondence, i.e., empirical accuracy. The two metatheories supplement each other, but are also incommensurable, i.e., they cannot be expressed in each other’s terms, for they employ completely different criteria to establish truth (Englebretsen in Bare facts and naked truths: a new correspondence theory of truth, Routledge, London, 2005). We will discuss both the role of both metatheories in medicine, in particular in medical education in a clinical context. In line with Hammond’s view (Med Decis Mak 16(3):281–287, 1996a; Human judgment and social policy: irreducible uncertainty, inevitable error, unavoidable injustice, Oxford University Press, New York, 1996b), we will extend the two metatheories to two forms of competence: coherence competence and correspondence competence, and demonstrate that distinguishing these two forms of competence increases our insights as to the best way to teach undergraduate students clinical problem solving. PubDate: 2019-01-22 DOI: 10.1007/s10459-018-09871-4
Authors:Francisco M. Olmos-Vega; Diana H. J. M. Dolmans; Carlos Guzmán-Quintero; Camila Echeverri-Rodriguez; Pim W. Teunnissen; Renée E. Stalmeijer Abstract: Maximising the potential of the workplace as a learning environment entails understanding the complexity of its members’ interactions. Although some articles have explored how residents engage with supervisors, nurses and pharmacists individually, there is little research on how residents enter into and engage with the broader community of clinical practice (CoCP). To this end, we designed a constructivist grounded theory study that took place at Universidad Javeriana in Bogotá, Colombia. We conducted semi-structured interviews with 13 residents from different training levels and disciplines during the first weeks of their new rotations. During the interviews, we used the Pictor technique as a visual aid to collect data. Using iterative data collection and analysis, constant comparison methods and theoretical sampling, we constructed the final results. When entering a CoCP, residents experienced recurring and intertwined processes including: exploring how their goals and interest are aligned with those of the CoCP; identifying the relevant CoCP members in the workplace environment; and understanding how these members could assist their successful engagement with the community’s practices. Residents entered a CoCP with the intention of either having a central or a peripheral trajectory in it. The final resident participation and role resulted from negotiations between the resident and the CoCP members. Optimising workplace learning includes being mindful as to how each member of the healthcare team influence residents’ engagement on practice, and on understanding the nuances of residents’ participatory trajectories while interacting with them. Understanding such nuances could be key to align CoCPs’ learning affordances and residents’ goals and intentions. PubDate: 2019-01-18 DOI: 10.1007/s10459-019-09874-9
Authors:Caroline Olsson; S. Kalén; S. Ponzer Abstract: Several studies have demonstrated that medical students and doctors rank specialties differently in terms of perceived status and prestige. At the same time some of the specialties have problems with recruiting and retaining staff. This study aimed to understand what constitutes status and prestige in the medical field and how it influences medical doctors’ choice of specialty. By using a sociological perspective and applying Bourdieu’s theoretical concepts of field, symbolic capital and perceived status, we analysed young doctors’ journeys towards their chosen specialty. We conducted 15 in-depth semi-structured interviews. The data was analysed using content analysis. The findings suggest that medical specialties carry different social status. In the field of power, surgery is seen as the most prestigious of all specialties. However, in the future it might be a less attractive choice when young doctors tend to view their profession less as an identity and more like a job. For specialties perceived as low status, the challenge is to raise popularity by better describing to young doctors the characteristics and advantages of these specialties. PubDate: 2019-01-17 DOI: 10.1007/s10459-018-09872-3
Authors:L. Dellenborg; E. Wikström; A. Andersson Erichsen Abstract: While person-centred care has gained increasing prominence in recent decades as a goal for healthcare systems, mainstream implementation remains tentative and there is a lack of knowledge about how to develop person-centred care in practice. This study therefore aimed to explore what may be required in order for person-centred care programmes to be successful. The study used an ethnographic method of data collection. This consisted of closely following an implementation programme on a medical emergency ward in a Swedish hospital. Data consisted of participant observation and informal interviews with healthcare providers and their management leaders while they were in the process of training to use person-centred care. These interlocutors were using action learning methods under the guidance of facilitators. Our findings revealed that although the programme resulted in some of the processes that are central for person-centred care being developed, organisational factors and a lack of attention to ethics in the programme counteracted these positive effects. The study highlights the importance of facilitating mechanisms to produce desired results. These include management leaders’ learning about the dynamic and collective nature of learning processes and change. They also include allowing for inter-professional dialogue to enable managers and professionals to reflect deeply on professional boundaries, disciplinary knowledge and power relations in their teams. Teamwork is essential for the development of person-centred care and documentation, in accordance with this specific implementation programme, is also indispensable. The space for inter-professional dialogue should also accommodate their various perspectives on the aims of care and organizational reality. PubDate: 2019-01-10 DOI: 10.1007/s10459-018-09869-y
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