Advances in Health Sciences Education

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Abstract

This paper argues that abductive reasoning has a central place in theorizing Health Professions Education. At the root of abduction lies a fundamental debate: How do we connect practice, which is always singular and unique, with theory, which describes the world in terms of rules, generalizations, and universals? While abduction was initially seen as the ‘poor cousin’ of deduction and induction, ultimately it has something important to tell us about the role of imagination and humility in theorizing Health Professions Education. It is that which makes theory possible, because it allows us to ask what might be the case and calls attention to the role of creative leaps in theory. Becoming aware of the abductive reasoning we already perform in our research allows us to take the role of imagination—something rarely associated with theory—seriously.

Posted: June 17, 2021, 12:00 am

Abstract

Studies primarily involving single health professions programs suggest that holistic review in admissions can increase underrepresented minority (URM) representation among admitted students. However, data showing little improvement in the overall proportion of URMs in many health professions, despite widespread use of holistic review, suggest that relatively few programs using holistic review admit substantial proportions of underrepresented minorities. Therefore, more research is needed to understand factors that facilitate holistic review practices that successfully promote diverse student enrollment. The literature suggests that a supportive organizational culture is necessary for holistic review to be effective; yet, the influence of culture on admissions has not been directly studied. This study employs a qualitative, multiple case study approach to explore the influence of a culture that values diversity and inclusion (‘diversity culture’) on holistic review practices in two physician assistant educational programs that met criteria consistent with a proposed conceptual framework linking diversity culture to holistic admissions associated with high URM student enrollment (relative to other similar programs). Data from multiple sources were collected at each program during the 2018–2019 admissions cycle, and a coding manual derived from the conceptual framework facilitated directed content analysis and comparison of program similarities and differences. Consistent with the conceptual framework, diversity culture appeared to be a strong driver of holistic admissions practices that support enrolling diverse classes of students. Additional insights emerged that may serve as propositions for further testing and include the finding that URM faculty ‘champions for diversity’ appeared to strongly influence the admissions process.

Posted: June 12, 2021, 12:00 am

Abstract

Cognitive Load Theory has emerged as an important approach to improving instruction in the health professions workplace, including patient handovers. At the same time, there is growing recognition that emotion influences learning through numerous cognitive processes including motivation, attention, working memory, and long-term memory. This study explores how emotion influences the cognitive load experienced by trainees performing patient handovers. From January to March 2019, 693 (38.7%) of 1807 residents and fellows from a 24-hospital health system in New York city completed a survey after performing a handover. Participants rated their emotional state and cognitive load. The survey included questions about features of the learner, task, and instructional environment. The authors used factor analysis to identify the core dimensions of emotion. Regression analyses explored the relationship between the emotion factors and cognitive load types. Two emotion dimensions were identified representing invigoration and tranquility. In regression analyses, higher levels of invigoration, tranquility, and their interaction were independently associated with lower intrinsic load and extraneous load. The interaction of invigoration and tranquility predicted lower germane load. The addition of the emotion variables to multivariate models including other predictors of cognitive load types significantly increased the amount of variance explained. The study provides a model for measuring emotions in workplace learning. Because emotion appears to have a significant influence on cognitive load types, instructional designers should consider strategies that help trainees regulate emotion in order to reduce cognitive load and improve learning and performance.

Posted: May 26, 2021, 12:00 am

Abstract

Competency frameworks provide a link between professional practice, education, training, and assessment. They support and inform downstream processes such as curriculum design, assessment, accreditation and professional accountability. However, existing guidelines are limited in accounting for the complexities of professional practice potentially undermining utility of such guidelines and validity of outcomes. This necessitates additional ways of “seeing” situated and context-specific practice. We highlight what a conceptual framework informed by systems thinking can offer when developing competency frameworks. Mirroring shifts towards systems thinking in program evaluation and quality improvement, we suggest that similar approaches that identify and make use of the role and influence of system features and contexts can provide ways of augmenting existing guidelines when developing competency frameworks. We framed a systems thinking approach in two ways. First using an adaptation of Ecological Systems Theory which offers a realist perspective of the person and environment, and the evolving interaction between the two. Second, by employing complexity thinking, which obligates attention to the relationships and influences of features within the system, we can explore the multiple complex, unique, and context-embedded problems that exist within and have stake in real-world practice settings. The ability to represent clinical practice when developing competency frameworks can be improved when features that may be relevant, including their potential interactions, are identified and understood. A conceptual framework informed by systems thinking makes visible features of a practice in context that may otherwise be overlooked when developing competency frameworks using existing guidelines.

Posted: May 18, 2021, 12:00 am

Abstract

Medical learners’ achievement emotions during educational activities have remained unexamined in Asian cultural contexts. The Medical Emotion Scale (MES) was previously developed to assess achievement emotions experienced by North American medical learners during learning activities. The goal of this study was to create and validate a Japanese version of the Medical Emotion Scale (J-MES). We translated the MES into Japanese and conducted two initial validation studies of the J-MES. In the first pilot study, we asked five, native-Japanese, second-year medical students to assess their emotions with the J-MES during a computer-based clinical reasoning activity. Each participant was then interviewed to assess the clarity and suitability of the items. In a second, larger study, 41 Japanese medical students were recruited to assess the psychometric properties of the J-MES. We also conducted individual, semi-structured interviews with ten of these participants to explore potential cultural features in the achievement emotions of Japanese students. The first pilot study demonstrated that the J-MES descriptions were clear, and that the scale captured an appropriate range of emotions. The second study revealed that the J-MES scale’s profiles and internal structure were largely consistent with control-value theory. The achievement emotions of pride, compassion, and surprise in the J-MES were found to be susceptible to cultural differences between North American and Japanese contexts. Our findings clearly demonstrated the scoring capacity, generalizability, and extrapolability of the J-MES.

Posted: May 12, 2021, 12:00 am

Abstract

The use of response formats in assessments of medical knowledge and clinical reasoning continues to be the focus of both research and debate. In this article, we report on an experimental study in which we address the question of how much list-type selected response formats and short-essay type constructed response formats are related to differences in how test takers approach clinical reasoning tasks. The design of this study was informed by a framework developed within cognitive psychology which stresses the importance of the interplay between two components of reasoning—self-monitoring and response inhibition—while solving a task or case. The results presented support the argument that different response formats are related to different processing behavior. Importantly, the pattern of how different factors are related to a correct response in both situations seem to be well in line with contemporary accounts of reasoning. Consequently, we argue that when designing assessments of clinical reasoning, it is crucial to tap into the different facets of this complex and important medical process.

Posted: May 11, 2021, 12:00 am

Abstract

Handover between colleagues is a complex task. The problem is that handovers are often inadequate because they are not structured according to theoretically grounded guidelines. Based on the cognitive load theory, we suggest that allowing a clarifying dialogue and thereby optimizing germane cognitive load enhances the information quality and diagnostic accuracy at handover, but may prolong handover duration. We also expect that mentioning key information first and thus decreasing intrinsic cognitive load improves information quality and diagnostic accuracy. We developed two representative paediatric cases for presentation in a factorial 2 × 2 design. Sixth-year medical students (N = 80) were randomly assigned to one of four groups that differed with regard to how the case histories were delivered to them (chronological order versus key information mentioned first) and direction of information exchange (unidirectional versus a clarifying dialogue). The receivers of the handover were asked to write a report of the cases and suggest the best diagnosis. Dependent variables were information quality of the written report (Information score), quality of the diagnosis (Diagnostic accuracy score) and the time it took to deliver the written handover case report (Handover report duration). Seen through the lens of cognitive load theory, allowing a clarifying dialogue at handover, and thus optimizing the germane cognitive load, significantly increased the Information score (p < 0.0005), Diagnostic accuracy score (< 0.05) and Handover report duration (p < 0.001).

Posted: May 1, 2021, 12:00 am

Abstract

Off-the-job faculty development for clinical teachers has been blighted by poor attendance, unsatisfactory sustainability, and weak impact. The faculty development literature has attributed these problems to the marginalisation of the clinical teacher role in host institutions. By focusing on macro-organisational factors, faculty development is ignoring the how clinical teachers are shaped by their everyday participation in micro-organisations such as clinical teams. We set out to explore how the roles of clinical teacher and graduate learner are co-constructed in the context of everyday work in clinical teams. Using an ethnographic study design we carried out marginal participant observation of four different hospital clinical teams. We assembled a dataset comprising field notes, participant interviews, images, and video, which captured day-to-day working and learning encounters between team members. We applied the dramaturgical sensitising concepts of impression management and face work to a thematic analysis of the dataset. We found that learning in clinical teams was largely informal. Clinical teachers modelled, but rarely articulated, an implicit curriculum of norms, standards and expectations. Trainees sought to establish legitimacy and credibility for themselves by creating impressions of being able to recognise and reproduce lead clinicians’ standards. Teachers and trainees colluded in using face work strategies to sustain favourable impressions but, in so doing, diminished learning opportunities and undermined educational dialogue. These finding suggest that there is a complex interrelationship between membership of clinical teams and clinical learning. The implication for faculty development is that it needs to move beyond its current emphasis on the structuring effects of institutional context to a deeper consideration of how teacher and learner roles are co-constructed in clinical teams.

Posted: May 1, 2021, 12:00 am

Abstract

Objective Structured Clinical Examinations (OSCEs) have become ubiquitous as a form of assessment in medical education but involve substantial resource demands and considerable local variation. A detailed understanding of the processes by which OSCEs are designed and administered could improve feasibility and sustainability. This exploration of OSCE design is informed by Practice Theory, which suggests assessment design processes are dynamic, social and situated activities. The overall purpose is to provide insights that inform on-the-ground OSCE administration. Fifteen interviews were conducted with OSCE academics and administrators from three medical schools in Australia, the United Kingdom and Canada. Drawing from post-qualitative inquiry, Schatzki’s Practice Theory was used both as a sensibility and as an analytic framework. OSCE design was characterised by planning activities, administration activities, negotiation activities and bureaucratic activities; it involves significant and resource-intensive effort in negotiation and coordination. There was considerable local variation but at the same time activities were remarkably consonant across national boundaries. There was a tension between general understandings such as reliability and validity that underpin the OSCE and the improvisational practices associated with design and administration. Our findings highlighted the role of blueprints as a key coordinating artefact but with too many rules and procedures prompting cycles of bureaucracy and complexity. Emphasising coordination rather than standardisation might ease workloads, support adaptation to local environments and prevent an overly reductive approach to this assessment format.

Posted: May 1, 2021, 12:00 am

Abstract

Students as partners is a movement which is gaining momentum in higher education, yet disciplinary perspectives are underexplored. Using a qualitative synthesis approach informed by Major and Savin-Baden (2010), we systematically investigated how health professional education has taken up the practice of working in partnership with students. Fifty-five publications were identified in our search from 2011 to -mid 2018. The majority of literature came from North America and medicine was the most frequently represented health profession. Our three stage analysis identified five key themes: (1) framing (i.e. ethos) of the partnership; (2) drivers for partnership; (3) sustainability; (4) inclusion of student voice; and (5) understanding of partnership and its benefits and challenges. Health professional educators are well equipped to enact partnership opportunities due to their clinical skills in person-centred care. However to gain the most from student-staff partnerships, health professional education would benefit from greater awareness of the field’s theoretical understandings of partnership and its key principles of reciprocity, respect and responsibility.

Posted: May 1, 2021, 12:00 am

Abstract

Practice-based interprofessional education (IPE), a key feature in developing a collaboration-ready workforce, is poorly integrated in healthcare curriculums. This study aimed to synthesise educator perspectives on implementing practice-based IPE and develop recommendations to inform sustainable practice-based IPE. An ethnographic case study was carried out at a school of allied health. Data collection involved six observations, 11 interviews and a review of eight documents. Reflexive thematic analysis, informed by Normalisation Process Theory, established two key themes. First, we found that strategic planning is needed, with a coherent implementation agenda and planned reflection on activities. Second, building partnerships with placement partners was identified as essential. This can be achieved by supporting and championing practice-based IPE activities developed by placement sites and establishing how university and clinical educators can work collaboratively to deliver sustainable practice-based IPE. These conditions create a favourable environment for normalising practice-based IPE in healthcare curriculums, benefitting students, patients, and the overall healthcare service.

Posted: May 1, 2021, 12:00 am

Abstract

While collaboration is an important and key attribute for medical students in order to prepare them to perform well in health care teams, how to effectively develop and assess such skills is challenging. The current widespread practice of using Likert-scale questionnaire only to measure the quantity of collaboration at course and/or program level appears to be insufficient to provide an evidence-base for what counts desirable collaborative learning experience. Drawing on research into student approaches to learning and social network analysis, this study investigates differences in collaborative learning configurations amongst 217 Australian medical students. Based on students’ learning orientations (i.e., ‘understanding’ and ‘reproducing’) and their choice of collaborations (i.e., whether to collaborate or not, with whom to collaborate, and mode of collaboration), the analyses found five configurations of collaborations differing in a number of features. The most desirable collaborative experience was a configuration of collaborations formed by students with an ‘understanding’ orientation. This configuration revealed a strong tendency towards intensive pair work with measurable differences in how easy and effectively they collaborated. The results of the study not only have practical implications for teaching and curriculum design for collaborative learning, but also have significant implications for assessing students’ collaborative learning experiences.

Posted: May 1, 2021, 12:00 am

Abstract

Variation in examiner stringency is an ongoing problem in many performance settings such as in OSCEs, and usually is conceptualised and measured based on scores/grades examiners award. Under borderline regression, the standard within a station is set using checklist/domain scores and global grades acting in combination. This complexity requires a more nuanced view of what stringency might mean when considering sources of variation of cut-scores in stations. This study uses data from 349 administrations of an 18-station, 36 candidate single circuit OSCE for international medical graduates wanting to practice in the UK (PLAB2). The station-level data was gathered over a 34-month period up to July 2019. Linear mixed models are used to estimate and then separate out examiner (n = 547), station (n = 330) and examination (n = 349) effects on borderline regression cut-scores. Examiners are the largest source of variation in cut-scores accounting for 56% of variance in cut-scores, compared to 6% for stations, < 1% for exam and 37% residual. Aggregating to the exam level tends to ameliorate this effect. For 96% of examinations, a ‘fair’ cut-score, equalising out variation in examiner stringency that candidates experience, is within one standard error of measurement (SEM) of the actual cut-score. The addition of the SEM to produce the final pass mark generally ensures the public is protected from almost all false positives in the examination caused by examiner cut-score stringency acting in candidates’ favour.

Posted: May 1, 2021, 12:00 am

Abstract

Gamification refers to using game attributes in a non-gaming context. Health professions educators increasingly turn to gamification to optimize students’ learning outcomes. However, little is known about the concept of gamification and its possible working mechanisms. This review focused on empirical evidence for the effectiveness of gamification approaches and theoretical rationales for applying the chosen game attributes. We systematically searched multiple databases, and included all empirical studies evaluating the use of game attributes in health professions education. Of 5044 articles initially identified, 44 met the inclusion criteria. Negative outcomes for using gamification were not reported. Almost all studies included assessment attributes (n = 40), mostly in combination with conflict/challenge attributes (n = 27). Eight studies revealed that this specific combination had increased the use of the learning material, sometimes leading to improved learning outcomes. A relatively small number of studies was performed to explain mechanisms underlying the use of game attributes (n = 7). Our findings suggest that it is possible to improve learning outcomes in health professions education by using gamification, especially when employing game attributes that improve learning behaviours and attitudes towards learning. However, most studies lacked well-defined control groups and did not apply and/or report theory to understand underlying processes. Future research should clarify mechanisms underlying gamified educational interventions and explore theories that could explain the effects of these interventions on learning outcomes, using well-defined control groups, in a longitudinal way. In doing so, we can build on existing theories and gain a practical and comprehensive understanding of how to select the right game elements for the right educational context and the right type of student.

Posted: May 1, 2021, 12:00 am
Posted: May 1, 2021, 12:00 am

Abstract

Although rhetoric abounds about the importance of patient-, person- and relationship-centered approaches to health care, little is known about how to address the problem of dehumanization through medical and health professions education. One promising but under-theorized strategy is to co-produce education in collaboration with health service users. To this end, we co-produced a longitudinal course in psychiatry that paired people with lived experience of mental health challenges as advisors to fourth-year psychiatry residents at the University of Toronto. The goal of this study was to examine this novel, relationship-based course in order to understand co-produced health professions education more broadly. Using qualitative interviews with residents and advisors after the first iteration of the course, we explored how participants made meaning of the course and of what learning, if any, occurred, for whom and how. We found that the anthropological theory of liminality allowed us to understand participants’ complex experiences and illuminated how this type of pedagogy may work to achieve its effects. Liminality also helped us understand why some participants resisted the course, and how we could more carefully think about co-produced, humanistic education and transformative learning.

Posted: May 1, 2021, 12:00 am

Abstract

The concept of quality culture has gained increased attention in health professions education, drawing on insights that quality management processes and positive work-related attitudes of staff in synergy lead to continuous improvement. However, the directions that guide institutions from quality culture theory to educational practice have been missing so far. A prospective qualitative case study of three health professions education programmes was conducted to explore how a quality culture can be enhanced according to the experiences and perspectives of educational leaders. The data collection was structured by an appreciative inquiry approach, supported with vignette-based interviews. A total of 25 participants (a selection of course coordinators, bachelor coordinators and directors of education) reflected on quality culture themes to learn about the best of what is (Discover), envision positive future developments (Dream), identify actions to reach the desired future (Design), and determine how to support and sustain improvement actions (Destiny) within their own educational setting. The results are presented as themes subsumed under these four phases. The experiences and perspectives of educational leaders reveal that peer learning in teams and communities, attention to professional development, and embedding support- and innovation networks, are at the heart of quality culture enhancement. An emphasis on human resources, (inter)relations and contextual awareness of leaders stood out as quality culture catalysts. Educational leaders are therefore encouraged to especially fuel their networking, communication, coalition building, and reflection competencies.

Posted: May 1, 2021, 12:00 am

Abstract

Global medical education is dominated by a Northern tilt. Global universities’ faculty and students dominate research, scholarship and teaching about what is termed global education. This tilt has been fixed in global biomedical education with some acknowledgement from the Global South of the comparative benefits of global exchange. Student exchange is predominantly North to South. Students from the Global South are less likely to visit the North on global medical education visits. Global indigenous and traditional ways of knowing rooted may be suppressed, hidden or misappropriated and repackaged for consumption in the Global South with Global North ways of knowing as a reference point. A global history of colonization has shaped this trend influencing postcolonial theorists and decolonial activists to question the legitimacy and depose the influence of dominant Global North ideas. This is evident in how communication skills, reflective practice and narratives are presented and taught. Global North students must be introduced to Global South ways of knowing before visiting the Global South from a position of critical consciousness. Emancipatory education is best led by transformative Global North–South dialogue.

Posted: May 1, 2021, 12:00 am

Abstract

The imperative for all healthcare professionals to partake in quality improvement (QI) has resulted in the development of QI education programs with participants from different professional backgrounds. However, there is limited empirical and theoretical examination as to why, when and how interprofessional and multiprofessional education occurs in QI and the outcomes of these approaches. This paper reports on a qualitative collective case study of interprofessional and multiprofessional education in three longitudinal QI education programs. We conducted 58 interviews with learners, QI project coaches, program directors and institutional leads and 135 h of observations of in-class education sessions, and collected relevant documents such as course syllabi and handouts. We used an interpretive thematic analysis using a conventional and directed content analysis approach. In the directed content approach, we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to understand the ways in which individuals’ professional backgrounds informed the planning and experiences of the QI education programs. Findings demonstrated that both interprofessional and multiprofessional education approaches were being used to achieve different education objectives. While each approach demonstrated positive learning and practice outcomes, tensions related to the different ways in which professional groups are engaging in QI, power dynamics between professional groups, and disconnects between curricula and practice existed. Further conceptual clarity is essential for a more informed discussion about interprofessional and multiprofessional education approaches in QI and explicit attention is needed to professional processes and tensions, to optimize the impact of education on practice.

Posted: May 1, 2021, 12:00 am

Abstract

The current study used theories on expertise development (the holistic model of image perception and the information reduction hypothesis) as a starting point to identify and explore potentially relevant process measures to monitor and evaluate expertise development in radiology residency training. It is the first to examine expertise development in volumetric image interpretation (i.e., CT scans) within radiology residents using scroll data collected longitudinally over five years of residency training. Consistent with the holistic model of image perception, the percentage of time spent on full runs, i.e. scrolling through more than 50% of the CT-scan slices (global search), decreased within residents over residency training years. Furthermore, the percentage of time spent on question-relevant areas in the CT scans increased within residents over residency training years, consistent with the information reduction hypothesis. Second, we examined if scroll patterns can predict diagnostic accuracy. The percentage of time spent on full runs and the percentage of time spent on question-relevant areas did not predict diagnostic accuracy. Thus, although scroll patterns over training years are consistent with visual expertise theories, they could not be used as predictors of diagnostic accuracy in the current study. Therefore, the relation between scroll patterns and performance needs to be further examined, before process measures can be used to monitor and evaluate expertise development in radiology residency training.

Posted: May 1, 2021, 12:00 am