Advances in Health Sciences Education

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Abstract

Medical students’ motivations for choosing a medical career are likely based on and remain tethered to the affectively-laden caring component of doctor–patient interactions. However, this component is rarely presented in educational surgical videos. It is unknown whether affectively engaging students by including patient-related emotionally salient information potentiates or draws focus away from learning a surgical procedure and whether such information affects motivation and attitudes toward the video. Therefore, we investigate whether presenting a patient’s emotional state before video surgery enhances or weakens the educational value of that video. In a within-subjects crossover design, second-year medical students (n = 130) viewed video clips of surgeries. These videos, from online medical education platforms, were preceded by the patient’s information from the original video or by information about the patient’s preoperative emotional preparation. After each video, participants completed a multiple-choice test about the video’s content to measure learning, answered a question about their motivation to re-watch the video, and completed an attitude scale regarding the video. Incorporating patient’s information into surgical videos significantly enhanced students’ acquisition of the technical aspects of surgery procedures (p < 0.0001), motivation to re-watch the video (p < 0.001), and favorable attitudes toward the video (p = 0.02). These findings show that incorporating information about patients’ emotional states may enhance students’ positive attitudes and motivations toward educational videos and may improve their learning of surgical techniques. They also suggest that the role of this factor should be considered when developing guidelines for medical educational video release.

Posted: October 1, 2020, 12:00 am

Abstract

Transitioning from student to doctor is notoriously challenging. Newly qualified doctors feel required to make decisions before owning their new identity. It is essential to understand how responsibility relates to identity formation to improve transitions for doctors and patients. This multiphase ethnographic study explores realities of transition through anticipatory, lived and reflective stages. We utilised Labov’s narrative framework (Labov in J Narrat Life Hist 7(1–4):395–415, 1997) to conduct in-depth analysis of complex relationships between changes in responsibility and development of professional identity. Our objective was to understand how these concepts interact. Newly qualified doctors acclimatise to their role requirements through participatory experience, perceived as a series of challenges, told as stories of adventure or quest. Rules of interaction within clinical teams were complex, context dependent and rarely explicit. Students, newly qualified and supervising doctors felt tensions around whether responsibility should be grasped or conferred. Perceived clinical necessity was a common determinant of responsibility rather than planned learning. Identity formation was chronologically mismatched to accepting responsibility. We provide a rich illumination of the complex relationship between responsibility and identity pre, during, and post-transition to qualified doctor: the two are inherently intertwined, each generating the other through successful actions in practice. This suggests successful transition requires a supported period of identity reconciliation during which responsibility may feel burdensome. During this, there is a fine line between too much and too little responsibility: seemingly innocuous assumptions can have a significant impact. More effort is needed to facilitate behaviours that delegate authority to the transitioning learner whilst maintaining true oversight.

Posted: October 1, 2020, 12:00 am

Abstract

Scoping reviews are increasingly used in health professions education to synthesize research and scholarship, and to report on the depth and breadth of the literature on a given topic. In this Perspective, we argue that the philosophical stance scholars adopt during the execution of a scoping review, including the meaning they attribute to fundamental concepts such as knowledge and evidence, influences how they gather, analyze, and interpret information obtained from a heterogeneous body of literature. We highlight the principles informing scoping reviews and outline how epistemology—the aspect of philosophy that “deals with questions involving the nature of knowledge, the justification of beliefs, and rationality”—should guide methodological considerations, toward the aim of ensuring the production of a high-quality review with defensible and appropriate conclusions. To contextualize our claims, we illustrate some of the methodological challenges we have personally encountered while executing a scoping review on clinical reasoning and reflect on how these challenges could have been reconciled through a broader understanding of the methodology’s philosophical foundation. We conclude with a description of lessons we have learned that might usefully inform other scholars who are considering undertaking a scoping review in their own domains of inquiry.

Posted: October 1, 2020, 12:00 am

Abstract

Models for diagnostic reasoning in radiology have been based on the observed behaviors of experienced radiologists but have not directly focused on the thought processes of novices as they improve their accuracy of image interpretation. By collecting think-aloud verbal reports, the current study was designed to investigate differences in specific thought processes between medical students (novices) as they learn and radiologists (experts), so that we can better design future instructional environments. Seven medical students and four physicians with radiology training were asked to interpret and diagnose pediatric elbow radiographs where fracture is suspected. After reporting their diagnosis of a case, they were given immediate feedback. Participants were asked to verbalize their thoughts while completing the diagnosis and while they reflected on the provided feedback. The protocol analysis of their verbalizations showed that participants used some combination of four processes to interpret the case: gestalt interpretation, purposeful search, rule application, and reasoning from a prior case. All types of processes except reasoning from a prior case were applied significantly more frequently by experts. Further, gestalt interpretation was used with higher frequency in abnormal cases while purposeful search was used more often for normal cases. Our assessment of processes could help guide the design of instructional environments with well-curated image banks and analytics to facilitate the novice’s journey to expertise in image interpretation.

Posted: October 1, 2020, 12:00 am

Abstract

The array of different philosophical positions underlying contemporary views on competence, assessment strategies and justification have led to advances in assessment science. Challenges may arise when these philosophical positions are not considered in assessment design. These can include (a) a logical incompatibility leading to varied or difficult interpretations of assessment results, (b) an “anything goes” approach, and (c) uncertainty regarding when and in what context various philosophical positions are appropriate. We propose a compatibility principle that recognizes that different philosophical positions commit assessors/assessment researchers to particular ideas, assumptions and commitments, and applies ta logic of philosophically-informed, assessment-based inquiry. Assessment is optimized when its underlying philosophical position produces congruent, aligned and coherent views on constructs, assessment strategies, justification and their interpretations. As a way forward we argue that (a) there can and should be variability in the philosophical positions used in assessment, and these should be clearly articulated to promote understanding of assumptions and make sense of justifications; (b) we focus on developing the merits, boundaries and relationships within and/or between philosophical positions in assessment; (c) we examine a core set of principles related to the role and relevance of philosophical positions; (d) we elaborate strategies and criteria to delineate compatible from incompatible; and (f) we articulate a need to broaden knowledge/competencies related to these issues. The broadened use of philosophical positions in assessment in the health professions affect the “state of play” and can undermine assessment programs. This may be overcome with attention to the alignment between underlying assumptions/commitments.

Posted: October 1, 2020, 12:00 am

Abstract

Undergraduate clinical assessors make expert, multifaceted judgements of consultation skills in concert with medical school OSCE grading rubrics. Assessors are not cognitive machines: their judgements are made in the light of prior experience and social interactions with students. It is important to understand assessors’ working conceptualisations of consultation skills and whether they could be used to develop assessment tools for undergraduate assessment. To identify any working conceptualisations that assessors use while assessing undergraduate medical students’ consultation skills and develop assessment tools based on assessors’ working conceptualisations and natural language for undergraduate consultation skills. In semi-structured interviews, 12 experienced assessors from a UK medical school populated a blank assessment scale with personally meaningful descriptors while describing how they made judgements of students’ consultation skills (at exit standard). A two-step iterative thematic framework analysis was performed drawing on constructionism and interactionism. Five domains were found within working conceptualisations of consultation skills: Application of knowledge; Manner with patients; Getting it done; Safety; and Overall impression. Three mechanisms of judgement about student behaviour were identified: observations, inferences and feelings. Assessment tools drawing on participants’ conceptualisations and natural language were generated, including ‘grade descriptors’ for common conceptualisations in each domain by mechanism of judgement and matched to grading rubrics of Fail, Borderline, Pass, Very good. Utilising working conceptualisations to develop assessment tools is feasible and potentially useful. Work is needed to test impact on assessment quality.

Posted: October 1, 2020, 12:00 am

Abstract

Competency frameworks serve various roles including outlining characteristics of a competent workforce, facilitating mobility, and analysing or assessing expertise. Given these roles and their relevance in the health professions, we sought to understand the methods and strategies used in the development of existing competency frameworks. We applied the Arksey and O’Malley framework to undertake this scoping review. We searched six electronic databases (MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, and ERIC) and three grey literature sources (greylit.org, Trove and Google Scholar) using keywords related to competency frameworks. We screened studies for inclusion by title and abstract, and we included studies of any type that described the development of a competency framework in a healthcare profession. Two reviewers independently extracted data including study characteristics. Data synthesis was both quantitative and qualitative. Among 5710 citations, we selected 190 for analysis. The majority of studies were conducted in medicine and nursing professions. Literature reviews and group techniques were conducted in 116 studies each (61%), and 85 (45%) outlined some form of stakeholder deliberation. We observed a significant degree of diversity in methodological strategies, inconsistent adherence to existing guidance on the selection of methods, who was involved, and based on the variation we observed in timeframes, combination, function, application and reporting of methods and strategies, there is no apparent gold standard or standardised approach to competency framework development. We observed significant variation within the conduct and reporting of the competency framework development process. While some variation can be expected given the differences across and within professions, our results suggest there is some difficulty in determining whether methods were fit-for-purpose, and therefore in making determinations regarding the appropriateness of the development process. This uncertainty may unwillingly create and legitimise uncertain or artificial outcomes. There is a need for improved guidance in the process for developing and reporting competency frameworks.

Posted: October 1, 2020, 12:00 am

Abstract

Teaching clinical reasoning in emergency medicine requires educators to foster diagnostic accuracy and judicious decision-making amidst chaotic ambient factors including clinician fatigue, high cognitive load, and diverse patient expectations. The current study applies the early work of Jurgen Habermas and his knowledge-constitutive interests as a lens to explore an educational approach where physician-educators were asked to make their expert reasoning visible to emergency medicine trainees, to more deliberately make visible and accessible the context-specific thinking that emergency physicians routinely use. An action research methodology was used. The ‘making thinking visible’ teaching approach was introduced to five emergency medicine educators working in large public hospital emergency departments. Participants were asked to trial this teaching method and document its impact on student learning over two reporting cycles. Based on written reports of trialing the teaching approach, participants identified a need to change from: (1) introducing thinking structures to cultivating enquiry; and, (2) providing explanations based on cognitive thinking routines towards encouraging the learner to see the relevance of the clinical context. Educators described how they developed a more diagnostic and reflexive approach to learners, recognized the need to cultivate independent thinking, and valued the opportunity to reflect on their usual teaching. Teaching clinical reasoning using the ‘making thinking visible’ approach prompted educators to decrease the emphasis on providing technical information to assisting learners to understand the purposes and meanings behind clinical reasoning in emergency medicine. The knowledge-constitutive interests work of Jurgen Habermas was found to provide a robust framework supporting this emancipatory teaching approach.

Posted: October 1, 2020, 12:00 am

Abstract

Healthcare graduates are often characterised as ill-prepared for workplace entry. Historically, research on health professional’s work preparedness has focused on the quality of graduates’ clinical knowledge, skills and problem-solving. This ignores the role of professional identity formation in determining readiness for clinical practice. Yet, professional identity defines graduate self-perception, how others perceive them and informs clinical behaviour. The scholarship of identity formation at the transition from undergraduate to graduate is characterised by individual (cognitive) rather than relational (sociocultural) perspectives. Yet there is growing recognition that identity formation is not just individually mediated, but is also constructed between individuals and social context. The aim of this study was to explore professional identity formation among undergraduates and graduates from one healthcare profession (speech and language therapy-SLT) using a sociocultural theoretical standpoint. A qualitative descriptive methodology was used. Final (4th) year SLT undergraduate students and graduate SLTs with less than 2 years’ clinical experience participated in individual semi-structured interviews. Thematic analysis was used to describe patterns in the data, which were subsequently subjected to interpretation informed by the constructs of Figured Worlds. Data analysis revealed that undergraduate professional identity was characterised by dependency, self-centredness (as opposed to patient-centredness), and a naïve role concept. Graduate identity on the other hand included expectations of self-sufficiency, patient-centredness and a more nuanced perception of the professional role. Undergraduates have naïve, prototypical understandings of what it is to be a graduate practitioner. The nature of undergraduate clinical placement hinders meaningful identity development. This suggests that curriculums should facilitate undergraduates to act with meaningful autonomy and to be positioned in more patient-centred roles, e.g. involvement in the decision-making process for patients. Graduates may then feel more authentic as autonomous professionals in their early graduate posts. This leads to better graduate, patient and service outcomes.

Posted: October 1, 2020, 12:00 am
Posted: October 1, 2020, 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: September 12, 2020, 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: September 2, 2020, 12:00 am

Abstract

The diversity of modern society is often not represented in the medical workforce. This might be partly due to selection practices. We need to better understand decision-making processes by selection committees in order to improve selection procedures with regard to diversity. This paper reports on a qualitative study with a socio-constructivist perspective conducted in 2015 that explored how residency selection decision-making occurred within four specialties in two regions in the Netherlands. Data included transcripts of the decision-making meetings and of one-on-one interviews with committee members before and after the group decision-making meetings. Candidates struggled to portray themselves favorably as they had to balance playing by the rules and being authentic; between fitting in and standing out. Although admissions committees had a welcoming stance to diversity, their practices were unintentionally preventing them from hiring underrepresented minority (URM) candidates. While negotiating admissions is difficult for all candidates, it is presumably even more complicated for URM candidates. This seems to be having a negative influence on attaining workforce diversity. Current beliefs, which make committees mistakenly feel they are acting fairly, might actually justify biased practices. Awareness of the role of committee members in these processes is an essential first step.

Posted: September 1, 2020, 12:00 am

Abstract

Theoretical understanding of what motivates clinician researchers has met with some success in launching research careers, but it does not account for professional identification as a factor determining sustained research engagement over the long-term. Deeper understanding of clinicians’ research-related motivation may better foster their sustained research engagement post-training and, by extension, the advancement of medicine and health outcomes. This study used an integrated theoretical framework (Social Cognitive Career Theory and Professional Identity Formation) and appreciative inquiry to explore the interplay of professional identification and research context in shaping post-training research success narratives. To foreground professional identification, 19 research-active clinicians and 17 basic scientists served as interviewees. A multi-institutional, multi-national design was used to explore how contextual factors shape external valuation of research success. The findings suggest that research-active clinicians do not identify as the career scientists implied by the modern physician-scientist construct and the goal of many clinician research-training programs. Their primary identification as care providers shapes their definition of research success around extending their clinical impact; institutional expectations and prevailing healthcare concerns that value this aim facilitate their sustained research engagement. Integrated developmental and organizational interventions adaptive to research context and conducive to a wider range of medical inquiry may better leverage clinicians’ direct involvement in patient care and advance progress toward human health and well-being.

Posted: August 25, 2020, 12:00 am

Abstract

Australian general practice trainees typically consult with patients from their first week of training, seeking in-consultation supervisory assistance only when not sufficiently confident to complete patient consultations independently. Trainee help-seeking plays a key role in supervisor oversight of trainee consultations. This study used focus groups and interviews with general practice supervisors to explore their approaches to trainee help-seeking and in-consultation supervision. Supervisor approaches are discussed under three themes: establishing a help-seeking culture; perceptions of in-consultation assistance required; and scripts for help provision. Within these themes, three interwoven entrustment processes were identified: supervisor entrustment; trainee self-entrustment; and ‘patient entrustment’ (patient confidence in the trainee’s clinical management). Entrustment appears to develop rapidly, holistically and informally in general practice training, partly in response to workflow pressure and time constraints. Typical supervisor scripts and etiquette for help-provision involve indirect, soft correction strategies to build trainee self-entrustment. These scripts appear to be difficult to adapt appropriately to under-performing trainees. Importantly, supervisor scripts also promote patient entrustment, increasing the likelihood of patients returning to the trainee and training practice for subsequent review, which is a major mechanism for ensuring patient safety in general practice. Theories of entrustment in general practice training must account for the interplay between supervisor, trainee and patient entrustment processes, and work-related constraints. Gaps between entrustment as espoused in theory, and entrustment as enacted, may suggest limitations of entrustment theory when extended to the general practice context, and/or room for improvement in the oversight of trainee consultations in general practice training.

Posted: August 24, 2020, 12:00 am

Abstract

In Canada, high stakes objective structured clinical examinations (OSCEs) administered by the Medical Council of Canada have relied exclusively on physician examiners (PEs) for scoring. Prior research has looked at using SPs to replace PEs. This paper reports on two studies that implement and evaluate a standardized patient (SP) scoring tool to augment PE scoring. The unique aspect of this study is that it explores the benefits of combining SP and PE scores. SP focus groups developed rating scales for four dimensions they labelled: Listening, Communication, Empathy/Rapport, and Global Impression. In Study I, 43 SPs from one site of a national PE-scored OSCE rated 60 examinees with the initial SP rating scales. In Study II, 137 SPs used slightly revised rating scales with optional narrative comments to score 275 examinees at two sites. Examinees were blinded to SP scoring and SP ratings did not count. Separate PE and SP scoring was examined using descriptive statistics and correlations. Combinations of SP and PE scoring were assessed using pass-rates, reliability, and decision consistency and accuracy indices. In Study II, SP and PE comments were examined. SPs showed greater variability in their scoring, and rated examinees lower than PEs on common elements, resulting in slightly lower pass rates when combined. There was a moderate tendency for both SPs and PEs to make negative comments for the same examinee but for different reasons. We argue that SPs and PE assess performance from different perspectives, and that combining scores from both augments overall reliability of scores and pass/fail decisions. There is potential to provide examinees with feedback comments from each group.

Posted: August 20, 2020, 12:00 am

Abstract

Research from outside the medical field suggests that social ties between team-members influence knowledge sharing, improve coordination, and facilitate task completion. However, the relative importance of social ties among team-members for patient satisfaction remains unknown. In this study, we explored the association between social ties within emergency teams performing simulated caesarean sections (CS) and patient-actor satisfaction. Two hundred seventy-two participants were allocated to 33 teams performing two emergency CSs in a simulated setting. We collected data on social ties between team-members, measured as affective, personal and professional ties. Ties were rated on 5-point Likert scales. In addition, participants’ clinical experience, demographic data and their knowledge about team members’ roles were surveyed. Perceived patient satisfaction was measured on a 5-point Likert scale. Data was analysed with a linear regression model using elastic net regularization. In total, 109 predictor variables were analysed including 84 related to social ties and 25 related to clinical experience, demographics and knowledge test scores. Of the 84 variables reflecting social ties, 34 (41%) had significant association with patient satisfaction, p < 0.01. By contrast, a significant association with patient satisfaction was found for only one (4%) of the 25 variables reflecting clinical experience, demographics and knowledge of team roles. Affective ties and personal ties were found to be far more important predictors in the statistical model than professional ties and predictors relating to clinical experience. Social ties between emergency team members may be important predictors of patient satisfaction. The results from this study help to enhance our conceptual understanding of social ties and their implications for team-dynamics. Our study challenges existing views of team-performance by placing emphasis on achieving collective competence through affective and personal social ties, rather than focusing on traditional measures of expertise.

Posted: August 1, 2020, 12:00 am

Abstract

Competency-based medical education and programmatic assessment intend to increase the opportunities for meaningful feedback, yet these conversations remain elusive. By comparing resident and faculty perceptions of feedback opportunities within one internal medicine residency training program, we sought to understand whether and how principles underlying meaningful feedback could be supported or constrained across a variety of feedback opportunities. Using case-study qualitative methodology, interviews and focus groups were conducted to explore 19 internal medicine residents’ and 7 faculty members’ perceptions of feedback across a variety of feedback opportunities: coaching, mini-CEXs, in-training evaluation reports and routine clinical supervision. Our data analysis moved iteratively between developing conceptual understandings and fine-grained analyses, while attending to both deductive and inductive analysis. Our results suggest that all feedback opportunities, including those created through formalized assessments, can foster meaningful feedback if faculty establish a trusting relationship with the resident, base their feedback on direct observation and support resident learning. However, formalized assessments were often perceived as inhibiting the conditions for meaningful feedback. A coaching program provided a context in which meaningful feedback could arise, in part because faculty were supported in shifting their focus from patient to resident. Meaningful feedback in clinical education may be fostered across a variety of feedback opportunities, however, it is often constrained by assessment. We must consider whether increasing the frequency of formative assessments may inhibit efforts to improve our feedback cultures while, in contrast, freeing up faculty to focus on supporting resident learning could improve these cultures.

Posted: August 1, 2020, 12:00 am
Posted: August 1, 2020, 12:00 am