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Introduction: The threshold concept framework (TCF) was first described nearly 20 years ago, but its application in the field of medical education has recently seen a significant growth of interest with a diverse range of literature published on the subject. The transformative nature of threshold concepts (TCs) offers potential for the design of learning experiences and curricula across the medical education continuum. A scoping review was conducted to map the extent of the current literature regarding TCs in medical education—to describe the types of available evidence and its focus—and identify research gaps. Methods: The review followed the JBI Manual for Evidence Synthesis approach for scoping reviews. Four databases and two additional websites were searched for articles exploring TCs in medical education. Data were analysed using quantitative and qualitative thematic approaches. A framework of conceptual change was used to synthesise the TCs identified. Results: Thirty‐six papers, spanning undergraduate, postgraduate and continuing medical education, were included in the final analysis. The most frequent application of the TCF was in the identification of TCs, which related to basic scientific knowledge, ways of thinking and ways of practising in medicine. Uncertainty, patient care, clinical reasoning and professional identify formation were themes that emerged at multiple stages of training. Several papers evaluated the use of the TCF in teaching. Conclusion: The understanding and embodiment of TCs increases in complexity across the medical education continuum, with TCs recurring with changes in clinical environment and responsibilities. This lends support to a holistic approach to curriculum design spanning all stages of training. Further research is needed to develop a consistent approach for describing and applying the TCF in medical education and to address how the TCF can be used in teaching and how threshold crossing can be measured. Understanding and embodiment of threshold concepts across the medical education continuum is argued through this review to support a holistic approach to curriculum design. [ABSTRACT FROM AUTHOR]

Introduction: The growing interest in knowledge translation and implementation science, both in clinical practice and in health professions education (HPE), is reflected in the number of studies that have sought to address what are believed to be evidence‐practice gaps. Though this effort may be intended to ensure practice improvements are better aligned with research evidence, there is a common assumption that the problems researchers explore and the answers they generate are meaningful and applicable to practitioner needs. Methods: This Mythology paper considers the nature of problems from HPE as the focus of HPE research and the ways in which they may or may not be aligned. The authors argue that, in an applied field such as HPE, it is vital that researchers better understand how their research problems relate to practitioner needs and what the limitations on evidence uptake might be. Not only can this establish clearer paths between evidence and action, but it also requires a rethink of much of knowledge translation and implementation science thinking and practice. Results: The authors explore five myths: whether everything in HPE is a problem; whether practitioner needs involve problem solving; whether practitioner problems are resolvable with sufficient evidence; whether researchers effectively target practitioner problems; and whether studies that focus on solving practitioner problems make significant contributions to the literature. Conclusions: To advance the conversation on the connections between problems and HPE research, the authors propose ways in which knowledge translation and implementation science might be approached differently. In the latest instalment of Medical Education Mythology, Thomas and Ellaway explore five myths surrounding "problems" in health professional education research and their impact on using research to guide practice. [ABSTRACT FROM AUTHOR]

Context: There have been significant advances in competency‐based medical education (CBME) within health professions education. While most of the efforts have focused on competency, less attention has been paid to the role of confidence as a factor in preparing for practice. This paper seeks to address this deficit by exploring the role of confidence and the calibration of confidence with regard to competence. Methods: This paper presents a conceptual review of confidence and the calibration of confidence in different medical education contexts. Building from an initial literature review, the authors engaged in iterative discussions exploring divergent and convergent perspectives, which were then supplemented with targeted literature reviews. Finally, a stakeholder consultation was conducted to situate and validate the provisional findings. Results: A series of axioms were developed to guide perceptions and responses to different states of confidence in health professionals: (a) confidence can shape how we act and is optimised when it closely corresponds to reality; (b) self‐confidence is task‐specific, but also inextricably influenced by the individual self‐conceptualisation, the surrounding system and society; (c) confidence is shaped by many external factors and the context of the situation; (d) confidence must be considered in conjunction with competence and (e) the confidence‐competence ratio (CCR) changes over time. It is important to track learners' CCRs and work with them to maintain balance. Conclusion: Confidence is expressed in different ways and is shaped by a variety of modifiers. While CBME primarily focuses on competency, proportional confidence is an integral component in ensuring safe and professional practice. As such, it is important to consider both confidence and competence, as well as their relationship in CBME. The CCR can serve as a key construct in developing mindful and capable health professionals. Future research should evaluate strategies for assessing CCR, identify best practices for teaching confidence and guiding self‐calibration of CCR and explore the role of CCR in continuing professional development for individuals and teams. @MGottliebMD @TChanMD @fzaver @drellaway review the concepts of confidence, competence, and the intersectionality between the two in this 'State of the Science' paper on "Self" in medical education. [ABSTRACT FROM AUTHOR]

Introduction: Like medicine and health care, feedback is a practice imbued with emotions: saturated with feelings relevant to one's identity and status within a given context. Often this emotional dimension of feedback is cast as an impediment to be ignored or managed. Such a perspective can be detrimental to feedback practices as emotions are fundamentally entwined with learning. In this critical review, we ask: What are the discourses of emotion in the feedback literature and what 'work' do they do? Methods: We conducted a critical literature review of emotion and feedback in the three top journals of the field: Academic Medicine, Medical Education and Advances in Health Sciences Education. Analysis was informed by a Foucauldian critical discourse approach and involved identifying discourses of emotion and interpreting how they shape feedback practices. Findings Of 32 papers, four overlapping discourses of emotion were identified. Emotion as physiological casts emotion as internal, biological, ever‐present, immutable and often problematic. Emotion as skill positions emotion as internal, mainly cognitive and amenable to regulation. A discourse of emotion as reflexive practice infers a social and interpersonal understanding of emotions, whereas emotion as socio‐cultural discourse extends the reflexive practice discourse seeing emotion as circulating within learning environments as a political force. Discussion Drawing on scholarship within the sociology of emotions, we suggest the merits of studying emotion as inevitable (not pathological), as potentially paralysing and motivating and as situated within (and often reinforcing) a hierarchical social health care landscape. For future feedback research, we suggest shifting towards recognising the discourse‐theory‐practice connection with emotion in health professional education drawing from reflexive and socio‐cultural discourses of emotion. This cross‐cutting edge article explores how effective feedback can be open to emotions and gauges how to leverage emotions for learning and practice. [ABSTRACT FROM AUTHOR]

Introduction: In light of reforms demanding increased transparency of student performance assessments, this study offers an in‐depth perspective of how teachers develop their assessment practice. Much is known about factors that influence assessments, and different solutions claim to improve the validity and reliability of assessments of students' clinical competency. However, little is known about how teachers go about improving their assessment practices. This study aims to contribute empirical findings about how teachers' assessment practice may change when shared criteria for assessing students' clinical competency are developed and implemented. Methods: Using a narrative‐in‐action research approach grounded in narrative theory about human sense‐making, one group including nine health professions teachers was studied over a period of 1 year. Drawing upon data from observations, interviews, formal documents and written reflections from these teachers, we performed a narrative analysis to reveal how these teachers made sense of experiences associated with the development and implementation of joint grading criteria for assessing students' clinical performances. Results: The findings present a narrative showing how a shared assessment practice took years to develop and was based on the teachers changed approach to scrutiny. The teachers became highly motivated to use grading criteria to ensure fairness in assessments, but more importantly, to fulfil their moral obligation towards patients. The narrative also demonstrates how these teachers reasoned about dilemmas that arose when they applied standardised assessment criteria. Discussion The narrative analysis shows clearly how teachers' development and application of assessment standards are embedded in local practices. Our findings highlight the importance of teachers' joint discussions on how to interpret criteria applied in formative and summative assessments of students' performances. In particular, teachers' different approaches to assessing 'pieces of skills' versus making holistic judgements on students' performances, regardless of whether the grading criteria are clear and well‐articulated on paper, should be acknowledged. Understanding the journey that these teachers made gives new perspectives as to how faculty can be supported when assessments of professionalism and clinical competency are developed. This study demonstrates how assessment practices change when performance criteria are developed. The findings highlight the importance of joint conversations between teachers and how their grading rationale shifts. [ABSTRACT FROM AUTHOR]

Context Review studies of simulation-based education ( SBE) consistently point out that theory-driven research is lacking. The literature to date is dominated by discourses of fidelity and authenticity - creating the 'real' - with a strong focus on the developing of clinical procedural skills. Little of this writing incorporates the theory and research proliferating in professional studies more broadly, which show how professional learning is embodied, relational and situated in social - material relations. A key concern for medical educators concerns how to better prepare students for the unpredictable and dynamic ambiguity of professional practice; this has stimulated the movement towards socio-material theories in education that address precisely this question. Objectives and Methods Among the various socio-material theories that are informing new developments in professional education, complexity theory has been of particular importance for medical educators interested in updating current practices. This paper outlines key elements of complexity theory, illustrated with examples from empirical study, to argue its particular relevance for improving SBE. Results Complexity theory can make visible important material dynamics, and their problematic consequences, that are not often noticed in simulated experiences in medical training. It also offers conceptual tools that can be put to practical use. This paper focuses on concepts of emergence, attunement, disturbance and experimentation. These suggest useful new approaches for designing simulated settings and scenarios, and for effective pedagogies before, during and following simulation sessions. Conclusions Socio-material approaches such as complexity theory are spreading through research and practice in many aspects of professional education across disciplines. Here, we argue for the transformative potential of complexity theory in medical education using simulation as our focus. Complexity tools open questions about the socio-material contradictions inherent in SBE, draw attention to important material dynamics of emergence, and suggest practical educative ways to expand and deepen student learning. [ABSTRACT FROM AUTHOR]

Context In 1988, the Edinburgh Declaration challenged medical teachers, curriculum designers and leaders to make an organised effort to change medical education for the better. Among a series of recommendations was a call to integrate training in science and clinical practice across a breadth of clinical contexts. The aim was to create physicians who could serve the needs of all people and provide care in a multitude of contexts. In the years since, in the numerous efforts towards integration, new models of curricula have been proposed and implemented with varying levels of success. Scope of Review In this paper, we examine the evolution of curricular integration since the Edinburgh Declaration, and discuss theoretical advances and practical solutions. In doing so, we draw on recent consensus reports on the state of medical education, emblematic initiatives reported in the literature, and developments in education theory pertinent to the role of integrated curricula. Conclusions Interest in integration persists despite 30 years of efforts to respond to the Edinburgh Declaration. We argue, however, that a critical shift has taken place with respect to the conception of integration, whereby empirical models support a view of integration as pertaining to both cognitive activity and curricular structure. In addition, we describe a broader definition of 'basic science' relevant to clinical practice that encompasses social and behavioural sciences, as well as knowledge derived from biomedical science. [ABSTRACT FROM AUTHOR]

In this commentary, @ChrisWatling3 highlights new papers by Schrepel and by Cantillon to consider the often problematic influences of medicine's professional subcultures on clinical practice and education. [ABSTRACT FROM AUTHOR]

Teodorczuk and Morris explore how novel research approaches, such as Cultural Historical Activity Theory, might shed light on how tensions can be negotiated as medical education continues to globalize. [ABSTRACT FROM AUTHOR]

Context: Exploring student intentions to practise in underserved areas (UAs) is necessary to inform the planning and training of the future medical workforce in order to increase effectiveness and fulfil societal needs. However, little is known about the motivational factors influencing these intentions. This paper explores medical students' intentions to practise in UAs and the motivational factors predicting these intentions. Methods: Eligible participants included graduating medical students from four of the five Swiss medical schools, who self‐reported specialty choice, intentions to practise in UAs, and motives that explained their career choices. Chi‐squared analysis was used to compare site, gender, specialty choice and UA practice intention. Motives were aggregated to obtain motivational factors using a principal component analysis with varimax rotation. Logistic regression was used to predict the effects of these motivational factors and of gender on UA practice intention. Results: Of 1749 students included in the study, 240 (13.7%) expressed an intention to practise in UAs (62.1% of whom intended to practise in rural areas) and 719 (41.1%) were undecided. In those who wished to practise in UAs, general practice (21.6%) was the most preferred specialty. Motivational factors influencing specialty choice were intellectual challenge, work variety, work conditions and enthusiasm (Kaiser‐Meyer‐Olkin index 0.79, P <.001, 49.0% of variance explained). Students motivated by work variety (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2‐1.7) and by work conditions (OR 1.3, 95% CI 1.1‐1.6) were more likely to choose UAs and those motivated by intellectual challenge (OR 0.4, 95% CI 0.3‐0.5) were less likely. Undecided students' motivations were very similar to those of students interested in working in UAs. Conclusions: The actual number of Swiss students interested in working in UAs is low and is probably insufficient to meet current societal needs. Work variety and work conditions appear to be factors that might attract interested and undecided students towards working in UAs. The authors showed that the actual number of Swiss students interested in working in underserved areas is insufficient to meet current societal needs. Work variety and work conditions seem to be targeting factors to attract interested and undecided students towards working in underserved areas. [ABSTRACT FROM AUTHOR]

Background: We examine the cultural myth of the medical meritocracy, whereby the "best and the brightest" are admitted and promoted within the profession. We explore how this narrative guides medical practice in ways that may no longer be adequate in the contexts of practice today. Methods: Narrative analysis of medical students' and physicians' stories. Results: Hierarchies of privilege within medicine are linked to meritocracy and the trope of the "hero's story" in literature. Gender and other forms of difference are generally excluded from narratives of excellence, which suggests operative mechanisms that may be contributory to observed differences in attainment. We discuss how the notion of diversity is formulated in medicine as a "problem" to be accommodated within merit, and posit that medical practice today requires a reformulation of the notion of merit in medicine, valorising a diversity of life experience and skills, rather than "retrofitting" diversity concerns as problems to be accommodated within current constructs of merit. Conclusions: Three main action‐oriented outcomes for a better formulation of merit relevant to medical practice today are suggested: (a) development of assessors' critical consciousness regarding the structural issues in merit assignment; (b) alignment of merit criteria with relevant societal outcomes, and (c) developing inclusive leadership to accommodate the greater diversity of excellence needed in today's context of medical practice. A reformulation of the stories through which medical practitioners and educators communicate and validate aspects of medical practice will be required in order for the profession to continue to have relevance to the diverse societies it serves. Is medicine a meritocracy or is it just a sotry we tell ourselves regarding who gets to be seen as excellent? The authors of this paper discuss the effect of the myth of meritocracy on recognition of diverse forms of excellence, offering suggestions for how to move forward. [ABSTRACT FROM AUTHOR]

Objective To develop and assess the feasibility and psychometric properties of multi-source feedback questionnaires to monitor international medical graduates practising in Canada under ‘defined’ licences. Method Four questionnaires (patient, co-worker, colleague and self) were developed and administered in 2 phases through paper-based and telephone or Internet formats. Reliability was assessed with Cronbach's alpha and generalisability coefficient analyses. Validity was established through mean ratings, ‘unable to respond’ rates and factor analyses. Results A total of 37 doctors participated in the 2 phases. Overall response rates were 70% for patients, 86% for co-workers, 72% for medical colleagues and 92% for self, with response rates higher for the paper-based format than the Internet and phone formats. The instruments had high internal consistency reliability, with Cronbach's alphas of 0.83 for self-assessment and > 0.90 for the other instruments. The generalisability coefficients were Ep2 = 0.71 for 25 patients on a 13-item survey, Ep2 = 0.59 for 8 co-workers on a 13-item survey, and Ep2 = 0.67 for 8 colleagues on a 21-item questionnaire. The range of mean scores was narrow (between 4 and 5) for all items and all surveys. The factor analyses identified that 2 factors accounted for 70% or more of the variance for the patient and colleague surveys and 60% of the variance for the co-worker survey. Conclusion These data suggest that the instruments have reasonable psychometric properties. Traditional survey methods (i.e. paper-based) yielded better results than Internet or phone methods for this group of doctors. [ABSTRACT FROM AUTHOR]

Background In recognition of the views advanced by the philosopher Maurice Merleau-Ponty, this paper considers some of the implications for medical practice and, hence, medical education, of recognizing the human body as an `intertwining' of the natural (or physical) and the existential (or experiential) – something which is taken for granted in ordinary experience, but which becomes the medium through which disease can manifest itself in illness and disability. Our condition is the condition of creatures of frail flesh. Perhaps because this `intertwining' is taken for granted, we tend to overlook the extent to which it is metaphysically astounding, even though it constitutes the daily arena and phenomena of clinical medicine. Clinical medicine is, among other things, the routine intervention in this intertwining. This fact is largely discounted by biomedical science, which concentrates on `the natural' at the expense of neglecting `the existential'. Such neglect arguably underlies the perceived deficiencies in medical education that the GMC sought to redress in its landmark document Tomorrow's Doctors . Proposal If the humanities disciplines concern themselves with recording and interpreting human experiences, the `medical humanities' do so for the human experiences of illness, disability and medical intervention. This paper argues for an integrated conception of the medical humanities, and for their incorporation into the core medical curriculum. The paper concludes by outlining a proposed core module in medical humanities, based around a syllabus divided not into the characteristic enquiries of constituent disciplines, but rather into groups of topics relating to key philosophical questions prompted by the `intertwining' in embodied human nature. [ABSTRACT FROM AUTHOR]

Context This paper presents a critique of current knowledge on the engagement of patients and the public, referred to here as patient and public involvement ( PPI), and calls for the development of robust and theoretically informed strategies across the continuum of medical education. Methods The study draws on a range of relevant literatures and presents PPI as a response process in relation to patient-centred learning agendas. Through reference to original research it discusses three key priorities for medical educators developing early PPI pedagogies, including: (i) the integration of evidence on PPI relevant to medical education, via a unifying corpus of literature; (ii) conceptual clarity through shared definitions of PPI in medical education, and (iii) an academically rigorous approach to managing complexity in the evaluation of PPI initiatives. Results As a response to these challenges, the authors demonstrate how activity modelling may be used as an analytical heuristic to provide an understanding of a number of PPI systems that may interact within complex and dynamic educational contexts. Conclusion The authors highlight the need for a range of patient voices to be evident within such work, from its generation through to dissemination, in order that patients and the public are partners and not merely objects of this endeavour. To this end, this paper has been discussed with and reviewed by our own patient and public research partners throughout the writing process. [ABSTRACT FROM AUTHOR]

Context: The shift in medical education from time‐based learning to outcome‐based learning has drawn much attention to entrustable professional activities (EPAs) as an ideal assessment framework to translate competencies into clinical practice. Given the relative novelty of EPAs, this review aims to highlight research gaps and explore and consolidate available evidence pertaining to the development and implementation of EPAs in health care. Method: Arksey and O'Malley's scoping review framework was used to present the findings. The authors performed a systematic search of PubMed, Embase, CINAHL, Scopus, MedNar, OpenGrey and ProQuest Dissertation and Theses for English articles published from the inception of each database to May 2018. A manual search of the reference lists of the included studies was conducted and an expert panel was consulted. Two reviewers screened the articles for eligibility using the inclusion criteria. All authors extracted key data and analysed the data descriptively. Thematic analysis was used to categorise the results into themes. Results: Eighty articles were included in the review. All articles were published between 2010 and 2018. Three major themes and eight sub‐themes were generated: (i) development of EPAs (frameworks for EPA development and implementation, identifying core or specialty‐specific EPAs, and EPAs for faculty development), (ii) evaluation of EPAs and EPA entrustment factors (revised curriculum, entrustment decisions for professional activities, and feedback on implemented EPAs and the development process), and (iii) future directions and recommendations for EPAs (implementation of EPAs in undergraduate medical education and specific disciplines, and other criticisms and recommendations for EPAs). Conclusions: Entrustable professional activities are an essential means to translate competencies into observable and measurable clinical practice. However, high‐level evidence‐based research on the efficacy, development and implementation of EPAs for specific target groups (i.e. undergraduates and staff) and geographical regions (i.e. Asia and Africa) is still lacking, which suggests a direction for future research. By reviewing the literature on Entrustable Professional Activities, Shorey et al. highlight an urgent need for high‐level evidence‐based research on the efficacy, development and implementation of EPAs for specific target groups. [ABSTRACT FROM AUTHOR]

Context: Historically, primary care (community and family) medicine has often been viewed as lower status than secondary care (hospital) practice. Current evidence suggests this pattern continues to impact medical practice and education. Medical education has however, yet to fully reflect this power dynamic, with undergraduate training in many institutions maintaining the hegemonic position of secondary care as the prime context for learning. Methods: In this paper, we present primary and secondary care as conflicting paradigms of medical practice. Using a sociocultural lens drawing on Figured Worlds theory, implications for medical education are explored. Conclusions: We outline the two paradigms as having distinct epistemologies, identities and practices. Tensions at the primary–secondary care interface can, from a sociocultural perspective, be seen to impact developing identity and day‐to‐day clinical practice issues such as patient safety. We offer possibilities for engaging with paradigm conflict in meaningful ways and suggest potential changes for future educational policy and practice. The authors dissect the longstanding tensions between primary and secondary care medicine, exploring how they impact on identity and learning in medical education. [ABSTRACT FROM AUTHOR]

Discusses the result of several research papers on the potential of learning in general practice. Undergraduate medical education; Practice training; Continuing professional development; Medical school.s

The article comments on the effectiveness of the technique of problem-based learning (PBL) within medical education. Since its introduction in 1960s, there are papers on theory and application of PBL amongst many involved in medical education. There are several concerns including whether PBL would seriously disrupt curricula that have been delivered effectively for many years. Moreover, a curriculum based on PBL is much more costly to administer than a conventional curriculum. The article presents a meta-analysis of the debate on the advantages of PBL over traditional method. PBL is said to have some advantages over the traditional curriculum in terms of student's satisfaction and approaches to study.

Context: Providing year‐long rural immersion as part of the medical degree is commonly used to increase the number of doctors with an interest in rural practice. However, the optimal duration and setting of immersion has not been fully established. This paper explores associations between various durations and settings of rural immersion during the medical degree and whether doctors work in rural areas after graduation. Methods: Eligible participants were medical graduates of Monash University between 2008 and 2016 in postgraduate years 1‐9, whose characteristics, rural immersion information and work location had been prospectively collected. Separate multiple logistic regression and multinomial logit regression models tested associations between the duration and setting of any rural immersion they did during the medical degree and (i) working in a rural area and (ii) working in large or smaller rural towns, in 2017. Results: The adjusted odds of working in a rural area were significantly increased if students were immersed for one full year (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.15–2.79), for between 1 and 2 years (OR, 2.26; 95% CI, 1.54–3.32) and for 2 or more years (OR, 4.43; 95% CI, 3.03–6.47) relative to no rural immersion. The strongest association was for immersion in a mix of both regional hospitals and rural general practice (OR, 3.26; 95% CI, 2.31–4.61), followed by immersion in regional hospitals only (OR, 1.94; 95% CI, 1.39–2.70) and rural general practice only (OR, 1.91; 95% CI, 1.06–3.45). More than 1 year's immersion in a mix of regional hospitals and rural general practices was associated with working in smaller regional or rural towns (<50 000 population) (relative risk ratios [RRR] 2.97; 95% CI, 1.82–4.83). Conclusion: These findings inform medical schools about effective rural immersion programmes. Longer rural immersion and immersion in both regional hospitals and rural general practices are likely to increase rural work and rural distribution of early career doctors. [ABSTRACT FROM AUTHOR]

Context: A key concern for surgical educators is to prepare students to perform in the operating room while ensuring patient safety. Recent years have seen a renewed discussion of medical education through practice theoretical and sociomaterial lenses. These lenses are introduced to understand and prepare the learner to perform in the given context. This paper takes its point of departure from practice theory by introducing a lens through which to understand learning environments in surgery. Methods: Using a multi‐site ethnographic and practice‐based design, this study investigates how aspiring surgical students are stirred into surgical practices and learn to engage as surgeons. During 70 hours of observations of medical students’ participation in the operating room, we analysed how the phenomenon of surgical learning can be perceived as instances of transformation in and among social practices. Results: By applying an analytical perspective, this article highlights the use of practice theory in surgical education, which can help to establish a firmer understanding of the learning environment and thereby help educators to improve curricula and prepare students more effectively to enter surgical training. Conclusions: The use of a practice theory adds the perspective that the education of surgeons needs to take the sayings, doings and relatings that constitute a surgical practice into account when preparing students to perform in their future workplace. In this way, surgical training can be perceived as a process of being stirred into practice. This means that one learns by participating in the practice of providing high‐quality care, where the aim is to teach students to be surgeons instead of teaching them to perform surgery. [ABSTRACT FROM AUTHOR]

Context Mixed methods research involves the collection, analysis and integration of both qualitative and quantitative data in a single study. The benefits of a mixed methods approach are particularly evident when studying new questions or complex initiatives and interactions, which is often the case in medical education research. Basic guidelines for when to use mixed methods research and how to design a mixed methods study in medical education research are not readily available. Methods The purpose of this paper is to remedy that situation by providing an overview of mixed methods research, research design models relevant for medical education research, examples of each research design model in medical education research, and basic guidelines for medical education researchers interested in mixed methods research. Conclusions Mixed methods may prove superior in increasing the integrity and applicability of findings when studying new or complex initiatives and interactions in medical education research. They deserve an increased presence and recognition in medical education research. [ABSTRACT FROM AUTHOR]

Context Video has long been recognised as providing an important resource within medical education, particularly, perhaps, for training in primary health care. As a resource for research, and more specifically within qualitative social science studies of medical practice, video has proved less pervasive, despite its obvious advantages. Methods In this paper, we sketch an approach to using video to inform the analysis of medical practice and the ways in which health care is accomplished through social interaction and collaboration. Drawing on our own research, we discuss two brief examples: the first involves the use of computing technology in primary health care and the second concerns informal instruction during surgery. The examples illustrate the multimodal character of medical work, how activities are accomplished through the interplay of talk, the visual and the use of material artefacts. They also illustrate the ways in which video provides access to the complex forms of social interaction and collaboration that underpin health care. Discussion We reflect upon the research opportunities afforded by video and the ways in which video-based studies of interaction can contribute to the practice and practicalities of medicine. [ABSTRACT FROM AUTHOR]

Practice inevitably narrows over time. Therefore, testing of established doctors requires that their assessment be tailored to a far narrower practice than is appropriate for testing of new doctors who have not yet differentiated. In this paper, we address the conceptual challenges of tailoring physician assessment to individual practice. Testing of established doctors needs to reflect that physicians specialise, often in idiosyncratic ways; otherwise, the testing will not be credible among established doctors and will not reflect the realities of their practice. Despite the importance of these goals, the conceptual and methodological challenges of creating tailored assessments remain daunting. [ABSTRACT FROM AUTHOR]

Summary The utility of any assessment tool critically depends on its level of acceptance by those on whom the assessment impacts. Performance assessment impacts on three distinct groups: patients/consumers, doctors and employers. While these groups may have conflicting beliefs and expectations of performance assessment, the process must be made acceptable to all. This can happen through an exploration of the beliefs and wishes of the key stakeholders in relation to performance assessment, together with the potential rewards and costs. This paper draws on the psychology literature in describing an effective model for change management. It outlines some strategies for each of the three key elements of any successful strategy for change, i.e. getting started, facilitating the transition and ensuring consolidation. Such a practical approach will foster the acceptance of performance assessment structures among all stakeholders. [ABSTRACT FROM AUTHOR]

Objective This paper aims to describe current views of the relationship between competence and performance and to delineate some of the implications of the distinctions between the two areas for the purpose of assessing doctors in practice. Methods During a 2-day closed session, the authors, using their wide experiences in this domain, defined the problem and the context, discussed the content and set up a new model. This was developed further by e-mail correspondence over a 6-month period. Results Competency-based assessments were defined as measures of what doctors do in testing situations, while performance-based assessments were defined as measures of what doctors do in practice. The distinction between competency-based and performance-based methods leads to a three-stage model for assessing doctors in practice. The first component of the model proposed is a screening test that would identify doctors at risk. Practitioners who ‘pass’ the screen would move on to a continuous quality improvement process aimed at raising the general level of performance. Practitioners deemed to be at risk would undergo a more detailed assessment process focused on rigorous testing, with poor performers targeted for remediation or removal from practice. Conclusion We propose a new model, designated the Cambridge Model, which extends and refines Miller's pyramid. It inverts his pyramid, focuses exclusively on the top two tiers, and identifies performance as a product of competence, the influences of the individual (e.g. health, relationships), and the influences of the system (e.g. facilities, practice time). The model provides a basis for understanding and designing assessments of practice performance. [ABSTRACT FROM AUTHOR]

Summary The assessment of the performance of doctors in practice is becoming more widely accepted. While there are many potential purposes for such assessments, sometimes the consequences of the assessments will be ‘high stakes’. In these circumstances, any of the many elements of the assessment programme may potentially be challenged. These assessment programmes therefore need to be robust, fair and defensible, taken from the perspectives of consumer, assessee and assessor. In order to inform the design of defensible programmes for assessing practice performance, a group of education researchers at the 10th Cambridge Conference adopted a project management approach to designing practice performance assessment programmes. This paper describes issues to consider in the articulation of the purposes and outcomes of the assessment, planning the programme, the administrative processes involved, including communication and preparation of assessees. Examples of key questions to be answered are provided, but further work is needed to test validity. [ABSTRACT FROM AUTHOR]

Context Although reflection is considered a significant component of medical education and practice, the literature does not provide a consensual definition or model for it. Because reflection has taken on multiple meanings, it remains difficult to operationalise. A standard definition and model are needed to improve the development of practical applications of reflection. Objectives This study was conducted in order to identify, explore and analyse the most influential conceptualisations of reflection, and to develop a new theory-informed and unified definition and model of reflection. Methods A systematic review was conducted to identify the 15 most cited authors in papers on reflection published during the period from 2008 to 2012. The authors' definitions and models were extracted. An exploratory thematic analysis was carried out and identified seven initial categories. Categories were clustered and reworded to develop an integrative definition and model of reflection, which feature core components that define reflection and extrinsic elements that influence instances of reflection. Results Following our review and analysis, five core components of reflection and two extrinsic elements were identified as characteristics of the reflective thinking process. Reflection is defined as the process of engaging the self (S) in attentive, critical, exploratory and iterative ( ACEI) interactions with one's thoughts and actions ( TA), and their underlying conceptual frame ( CF), with a view to changing them and a view on the change itself ( VC). Our conceptual model consists of the defining core components, supplemented with the extrinsic elements that influence reflection. Conclusions This article presents a new theory-informed, five-component definition and model of reflection. We believe these have advantages over previous models in terms of helping to guide the further study, learning, assessment and teaching of reflection. [ABSTRACT FROM AUTHOR]

The article focuses on the papers presenting the career intentions of graduates of 2002 which made an important contribution to the development of workforce planning policy in Great Britain. The authors of the study compare the career choices of these graduates with those of 1999 and 2000 graduates including the number of specialists currently in medical practice in England.

Context In current debates about professional practice and education, increasing emphasis is placed on understanding learning as a process of ongoing participation rather than one of acquiring knowledge and skills. However, although this socio-cultural view is important and useful, issues have emerged in studies of practice-based learning that point to certain oversights. Methods Three issues are described here: (i) the limited attention paid to the importance of materiality - objects, technologies, nature, etc. - in questions of learning; (ii) the human-centric view of practice that fails to note the relations among social and material forces, and (iii) the conflicts between ideals of evidence-based standardised models and the sociomaterial contingencies of clinical practice. Discussion It is argued here that a socio-material approach to practice and learning offers important insights for medical education. This view is in line with a growing field of research in the materiality of everyday life, which embraces wide-ranging families of theory that can be only briefly mentioned in this short paper. The main premise they share is that social and material forces, culture, nature and technology, are enmeshed in everyday practice. Objects and humans act upon one another in ways that mutually transform their characteristics and activity. Examples from research in medical practice show how materials actively influence clinical practice, how learning itself is a material matter, how protocols are in fact temporary sociomaterial achievements, and how practices form unique and sometimes conflicting sociomaterial worlds, with diverse diagnostic and treatment approaches for the same thing. Conclusions This discussion concludes with implications for learning in practice. What is required is a shift from an emphasis on acquiring knowledge to participating more wisely in particular situations. This focus is on learning how to attune to minor material fluctuations and surprises, how to track one's own and others' effects on 'intra-actions' and emerging effects, and how to improvise solutions. [ABSTRACT FROM AUTHOR]

Medical Education 2011: 45: 1072-1080 Context Mind wandering - defined as a cognitive focus on information that is unrelated to immediate sensory input or the task at hand - is a ubiquitous characteristic of the human condition. When it occurs, the integrity of a wide range of cognitive skills can be compromised. Objectives The current paper describes the phenomenon of mind wandering, explores its potential role in medical practice and considers how the education system may profitably control this ubiquitous cognitive state. Methods We argue that because many aspects of a medical professional's work (such as fatigue and depression) maximise the mind's tendency to wander, this experience is likely to be a common occurrence in many medical situations. We then review the psychological literature on mind wandering as it relates to medical practice. Conclusions Based on this review, we suggest that because mind wandering interferes with an individual's ability to integrate current events into a more general context, its occurrence may lead to downstream problems in the way that symptoms are interpreted and treated. Finally, because the experience of mind wandering is often both difficult to control and hard to recognise, it is difficult to prevent. We argue that techniques that help individuals to become more mindful have the potential to ameliorate the cost of mind wandering to the medical profession. Given the ubiquitous nature of the experience of mind wandering, the integration of mindfulness training into medical education programmes could be of general benefit to society at large. [ABSTRACT FROM AUTHOR]

Background The assessment of clinical procedural skills has traditionally focused on technical elements alone. However, in real practice, clinicians are expected to be able to integrate technical with communication and other professional skills. We describe an integrated procedural performance instrument (IPPI), where clinicians are assessed on 12 clinical procedures in a simulated clinical setting which combines simulated patients (SPs) with inanimate models or items of medical equipment. Candidates are observed remotely by assessors whose data are fed back to the clinician within 24 hours of the assessment. This paper describes the feasibility of IPPI. Results A full-scale IPPI and 2 pilot studies with trainee and qualified health care professionals has yielded an extensive data set including 585 scenario evaluations from candidates, 60 from clinical assessors and 31 from simulated patients (SPs). Interview and questionnaire data showed that for the majority of candidates IPPI provided a powerful and valuable learning experience. Realism was rated highly. Remote and real-time assessment worked effectively, although for some procedures limited camera resolution affected observation of fine details. Discussion IPPI offers an innovative approach to assessing clinical procedural skills. Although resource-intensive, it has the potential to provide insight into individual's performance over a spectrum of clinical scenarios and at no risk to the safety of patients. Additional benefits of IPPI include assessment in real time from experts (allowing remote rating by external examiners) as well as provision of feedback from simulated patients. [ABSTRACT FROM AUTHOR]

Background The continued reduction in junior doctors' hours in the UK has made it necessary to re-examine traditional assumptions about the synonymous natures of training and service. This paper researches senior house officers' (SHOs) perceptions of ‘service’ and ‘training’, with reference to where they place activities along the training/service continuum, and the factors that lead them to classify these activities in the way they do. Methods Questionnaires were sent to all identified SHOs at Plymouth Hospitals NHS Trust (40% response rate). Three focus groups were held with 5 SHOs, 3 consultants and 2 clinical tutors. Quantitative data derived from the questionnaires were analysed usingspss. Qualitative data collected in the focus groups was coded with the aid ofn6, which facilitated the thematic analysis of transcripts. Results Analysis of the quantitative data allowed the construction of the training/service continuum diagram. Identified factors affecting the perceived training/service balance of SHO activities included: frequency, time, type and nature of work, number of patients, supervision, interaction, other commitments, purpose and focus of the activity, the individual trainee and trainer, and experience and competence. Discussion It is no longer appropriate to assume that all junior doctor activities represent either training or service individually: activities are perceived differently along the training/service continuum depending on their execution and their relation to the SHOs' learning curves. Within the reduced hours framework, it is necessary to match this balance to experience, in order for both training and service requirements to be satisfied. [ABSTRACT FROM AUTHOR]

To explore the generalised application of a discourse of cost reduction in the practice of medicine in the USA. Changes in the health services industry over the last 20 years have left much concern in the hearts and minds of many, providers and patients alike. Even for the millions of Americans who are able to purchase health insurance, the standard of care has changed. In some ways, the current managed-care climate has created an atmosphere of distrust between patients and their providers, and, more significantly, a general sense of dissatisfaction with the state of health care in the USA. In the midst of this discontent, health providers have begun to question their own roles in what is increasingly a for-profit health care system. Not surprisingly, medical educators now question whether the current health system is creating a new generation of doctors who are concerned with reducing costs without adequate review of clinical data. This paper examines the rationale applied in the management of a patient with end-stage liver disease in a teaching hospital. The case is re-socialised by situating it in an ethical discourse linked to the function of the for-profit health system. The decision about whether to give human albumin to an insured patient serves as a lens through which to examine how uncritical appeals to the discourse of ‘cost-effectiveness’ can supersede a patient- and data-oriented approach to medical decision making. This case illustrates the permeation of economic considerations into the core values of medicine, highlighting a detrimental ethical shift occurring in the field. The training of new doctors represents a site from which to resist this unwelcome transformation. [ABSTRACT FROM AUTHOR]

At the end of training, students seem to lack a basic understanding of how to take an organised, relevant medical and social history using a patient-centred approach. The aim of developing the map described in this paper was to provide a framework for such an approach. Action research was used to continuously modify and refine an interview map that was used by medical clerks, family medicine residents, international medical graduates and practising doctors for teaching and learning purposes over a 10-year period. ‘Martin's Map' provides a realistic framework for flexibly organising and integrating medical content with process that did not previously exist. The map provides medical educators with a standardised framework for talking about the medical interview, which helps learners understand how to use their medical knowledge with a patient-centred approach. Learners are able to visually see how they can take a focused medical and social history using a patient-centred approach, which subsequently seems to help them organise their thinking and approach during the medical encounter. [ABSTRACT FROM AUTHOR]

Background Some doctors who perform poorly appear not to be aware of how their performance compares with accepted practice. The way that professionals maintain their existing expertise and acquire new knowledge and skills – that is, maintain their ‘currency’ of practice – requires a capacity to change. This capacity to change probably requires the individual doctor to possess insight into his or her performance as well as motivation to change. There may be a range of levels of insight in different individuals. At some point this reaches a level which is inadequate for effective self-regulation. Insight and performance may be critically related and there are instances where increasing insight in the presence of decreasing performance can also cause difficulties. Objective This paper presents an exploration into the nature of insight, its relationship to professional performance and its measurement as part of performance, reflecting the combined experiences of a group of experienced education researchers and the results of literature searches on insight and performance. Conclusion There may be individuals in whom insight is so lacking that they are beyond remediation. If there is a dichotomy between adequate and inadequate levels of insight, testing this could be a cost-effective way of determining where efforts for remediation should be focussed. [ABSTRACT FROM AUTHOR]

Background The use of portfolios can potentially provide flexibility in the summative assessment of doctors in practice. An assessment system should reflect and reinforce the active and planned professional development goals of individual doctors. This paper discusses some of the issues involved in developing such a system. Results To provide a complete picture of an individual doctor's practice, we suggest that a portfolio should encompass: (1) evidence covering all three domains of patient care, personal development and context management; (2) evidence that the person continuously undertakes critical assessment of their own performance, identifies and prioritises areas requiring enhanced performance and takes action to improve them as appropriate; (3) evidence that has been generated by assessments that are acceptably reliable, and (4) evidence which, taken in its entirety, is sufficient, valid, current and authentic. We include a suggested outline of the components of such a portfolio and suggest some criteria to determine the effectiveness of learning cycles. Portfolio reliability and validity requires sufficient evidence on which to base a judgement combined with reliable processes. Conclusion Carefully specified portfolios can contribute to a system that ensures all doctors take an active part in identifying and meeting their own learning needs. Such a system, if properly implemented, would have a greatly beneficial impact on continuous quality improvement for the profession in general. [ABSTRACT FROM AUTHOR]

Background If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime's storehouse of knowledge. Rather a doctor's ongoing learning is a ‘journey’ across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and community issues. Objectives In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired performance, define educational need and initiate educational action. Method To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess. Conclusions We conclude by exploring the implications of this model for integrated medical services, highlighting the actions and directions that would be required of doctors, medical and professional organisations, universities and other continuing education providers, credentialling bodies and governments. [ABSTRACT FROM AUTHOR]

Context The responsibility to determine just who is competent to practice medicine, and at what standard, is great. Whilst there is still a period available for potential remediation, examinations at the completion of year three of the four-year Graduate Entry Medical Programme (GEMP) at Flinders University of South Australia (FUSA) are high stakes and contain the majority of final summative assessment for the certification of student to doctor. Therefore, the medical school has recently examined its methods for certification, the clinical practice standards sought in its programme and how to determine these standards. Design For all assessments a standard was documented and methods employed to set these standards using specific measures of performance. A modification of the Angoff method was applied to the written examination and the Rothman method, using two criteria, was used to determine competency in the objective structured clinical examination (OSCE). These methods were used for the first time in 1998. Both methods used trained ‘experts’ as standard setters and both methods used the notion of the ‘borderline candidate’ to determine the passing standard. This paper describes these two criterion-referenced standard-setting procedures as used in this school and related examination performance. Conclusions Whilst the use of standard-setting procedures goes part way to defining and measuring competence, it is time consuming and requires significant examiner training and acceptance. Using 50% to determine who is and isn’t competent is simpler but not transparent, fair nor defensible. [ABSTRACT FROM AUTHOR]

Winkel and Morgan reflect on the importance of educators helping trainees to balance the inevitable tension between engaging with challenges and experiencing stressors that impair wellbeing. To do so, they advocate for an individualized approach to supervision. [ABSTRACT FROM AUTHOR]

In the article, the author discusses the importance of rural medical education research in the professional identity development of medical educators, physicians and other health care professionals. Also cited are the need for medical schools to produce professionals who will serve the communities around their educational institutions, and the key effect of a dose-response relationship in the decision of learners to practise in a rural region.

The article discusses national licensing examinations (NLEs) in medical education. It references the article "Trends in national licensing examinations in medicine" by D. B. Swanson and T. E. Roberts, which appears elsewhere in the issue. Details on the relationship between assessment in medical education and NLEs are presented. Other topics include public attitudes towards the quality of medical graduates, data collection and interpretation, and the relationship between assessment and learning.

The article discusses curriculum design in medical education. It references the author's article in a previous issue of the journal, entitled "The Emperor's New Clothes: From Objectives to Outcome" as well as the article "The Promise, Perils, Problems, and Progress of Competency-Based Education" by C. Touchie and O. ten Cate, which appears in the current issue. Topics discussed include competency-based medical education, outcomes-based education, and entrustable professional activities (EPAs).

This study aimed to compare an essay-style undergraduate medical assessment with modified essay, multiple-choice question (MCQ) and objective structured clinical examination (OSCE) undergraduate medical assessments in predicting students' clinical performance (predictive validity), and to determine the relative contributions of the written (modified essay and MCQ) assessment and OSCE to predictive validity.Before and after cohort study.One medical school running a 6-year undergraduate course.Study participants included 137 Year 5 medical students followed into their trainee intern year.Aggregated global ratings by senior doctors, junior doctors and nurses as well as comprehensive structured assessments of performance in the trainee intern year.Students' scores in the new examinations predicted performance significantly better than scores in the old examinations, with correlation coefficients increasing from 0.05−0.44 to 0.41–0.81. The OSCE was a stronger predictor of subsequent performance than the written assessments but combining assessments had the strongest predictive validity.Using more comprehensive, more reliable and more authentic undergraduate assessment methods substantially increases predictive validity. [ABSTRACT FROM AUTHOR]

Research has shown that taking 'timeouts' in medical practice improves performance and patient safety. However, the benefits of taking timeouts, or pausing, are not sufficiently acknowledged in workplaces and training programmes. To promote this acknowledgement, we suggest a systematic conceptualisation of the medical pause, focusing on its importance, processes and implementation in training programmes. By employing insights from educational and cognitive psychology, we first identified pausing as an important skill to interrupt negative momentum and bolster learning. Subsequently, we categorised constituent cognitive processes for pausing skills into two phases: the decision‐making phase (determining when and how to take pauses) and the executive phase (applying relaxation or reflection during pauses). We present a model that describes how relaxation and reflection during pauses can optimise cognitive load in performance. Several strategies to implement pause training in medical curricula are proposed: intertwining pause training with training of primary skills, providing second‐order scaffolding through shared control and employing auxiliary tools such as computer‐based simulations with a pause function. Lee et al. suggest a systematic conceptualization of the medical pause, focusing on its importance, processes, and implementation in training programs. [ABSTRACT FROM AUTHOR]

Objectives: Managing uncertainty is central to expert practice, yet how novice trainees navigate these moments is likely different than what has been described by experienced clinicians. Exploring trainees' experiences with uncertainty could therefore help explicate the unique cues that they attend to, how they appraise their comfort in these moments and how they enact responses within the affordances of their training environment. Methods: Informed by constructivist grounded theory, we explored how novice emergency medicine trainees experienced and managed clinical uncertainty in practice. We used a critical incident technique to prompt participants to reflect on experiences with uncertainty immediately following a clinical shift, exploring the cues they attended to and the approaches they used to navigate these moments. Two investigators coded line‐by‐line using constant comparison, organising the data into focused codes. The research team discussed the relationships between these codes and developed a set of themes that supported our efforts to theorise about the phenomenon. Results: We enrolled 13 trainees in their first two years of postgraduate training across two institutions. They expressed uncertainty about the root causes of the patient problems they were facing and the potential management steps to take, but also expressed a pervasive sense of uncertainty about their own abilities and their appraisals of the situation. This, in turn, led to challenges with selecting, interpreting and using the cues in their environment effectively. Participants invoked several approaches to combat this sense of uncertainty about themselves, rehearsing steps before a clinical encounter, checking their interpretations with others and implicitly calibrating their appraisals to those of more experienced team members. Conclusions: Trainees' struggles with the legitimacy of their interpretations impact their experiences with uncertainty. Recognising these ongoing struggles may enable supervisors and other team members to provide more effective scaffolding, validation and calibration of clinical judgments and patient management. The authors demonstrate that trainees cope with distrust of their appraisals of uncertainty by rehearsing steps, checking interpretations with others, and calibrating their impressions with more experienced team members. [ABSTRACT FROM AUTHOR]

Ajjawi highlights tensions regarding research quality in diverse fields such as medical education. Is open peer‐review the answer? [ABSTRACT FROM AUTHOR]

In this article, the authors discuss several studies which assess the behaviour of newly qualified doctors in caring for acutely unwell patients and the impact of transitions on junior doctors' medical performance. They state that the studies could result to a problem which arises from different approaches to training medical doctors. They also note that the studies show that transitions in medical performance are prolonged developmental processes.

Almoghirah et al. reflect on the many variables that influence individual performance within collaborative work, offering insight into the power of personalised, subjective and contextualised assessment and feedback. [ABSTRACT FROM AUTHOR]