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Entrustable professional activities (EPAs), discrete profession-specific tasks requiring integration of multiple competencies, are increasingly used to help define and inform curricula of specialty training programmes. Although guidelines exist to help guide the developmental process, deciding what logic to use to draft a preliminary EPA framework poses a crucial but often difficult first step. The logic of an EPA framework can be defined as the perspective used by its developers to break down the practice of a profession into units of professional work. This study aimed to map dominant logics and their rationales across postgraduate medical education and fellowship programmes.A scoping review using systematic searches within five electronic databases (Medline, Embase, Google Scholar, Scopus and Web of Science) was performed. Dominant logics of included papers were identified using inductive coding and iterative analysis.In total, 42 studies were included. Most studies were conducted in the United States (n = 22; 52%), Canada (n = 6; 14%) and the Netherlands (n = 4; 10%). Across the reported range of specialties, family medicine (n = 4; 10%), internal medicine (n = 4; 10%), paediatrics (n = 3; 7%) and psychiatry (n = 3; 7%) were the most common. Three dominant logics could be identified, namely, 'service provision', 'procedures' and/or 'disease or patient categories'. The majority of papers (n = 37; 88%) used two or more logics when developing EPA frameworks (median = 3, range = 1-4). Disease or patient groups and service provision were the most common logics used (39% and 37%, respectively).Most programmes used a combination of logics when trying to capture the essential tasks of a profession in EPAs. For each of the three dominant logics, the authors arrived at a definition and identified benefits, limitations and examples. These findings may potentially inform best practice guidelines for EPA development.

Context With many health and social care schools offering mindfulness training (MT) there is a need for deeper understanding about pedagogical issues. Despite encouraging findings showing relationships between MT and student stress reduction, there is little qualitative synthesis of the literature about best principles for teaching and learning. Methods We report on a qualitative scoping review using the stages of Arksey and O'Malley's framework. The search identified papers from MEDLINE, PsychINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and SCOPUS over 15 years. The included papers were synthesised using the 3P model of teaching and learning to explore current MT for presage (teaching set-up), process (teaching delivery) and product (outcomes) factors. Results A total of 16 articles were included in the review. There was a lack of consensus on definition of MT, facilitator training and the intervention used. The majority of studies involved small self-selected, mainly female cohorts. For the set-up (presage factors), the majority of curricula included MT for stress management and well-being, delivered in the early years. Providing appropriate facilitators was a concern, whereas process factors revealed enormous variability in delivery. Few studies had formal assessment, although many had outcome evaluation measures (product factors). Conclusions The qualitative review has highlighted additional benefits from MT aside from stress reduction; most noticeably, student self-awareness, peer cohesion and group support, ability to attend to patients, and student insights into health and social education culture. Seeking presage, process and product factors has illuminated variability in how MT is being adapted within health and social care curricula. This review highlights the next steps and recommendations for the future.

Summary As a reflection on the Edinburgh Declaration, this conceptual synthesis presents six important challenges in relation to the role of medical education in meeting current national health priorities. Context This paper presents a conceptual synthesis of current efforts in medical education to incorporate national health priorities as a reflection on how the field has evolved since the Edinburgh Declaration. Considering that health needs vary from country to country, our paper focuses on three broad and cross‐cutting themes: health equity, health systems strengthening, and changing patterns of disease. Methods Considering the complexity of this topic, we conducted a targeted search to broadly sample and critically review the literature in two phases. Phase 1: within each theme, we assessed the current challenges in the field of medical education to meet the health priority. Phase 2: a search for various strategies in undergraduate and postgraduate education that have been tested in an effort to address the identified challenges. We conducted a qualitative synthesis of the literature followed by mapping of the identified challenges within each of the three themes with targeted efforts. Findings We identified six important challenges: (i) mismatch between the need for generalist models of health care and medical education curricula's specialist focus; (ii) attitudes of health care providers contributing to disparities in health care; (iii) the lack of a universal approach in preparing medical students for 21st century health systems; (iv) the inability of medical education to keep up with the abundance of new health care technologies; (v) a mismatch between educational requirements for integrated care and poorly integrated, specialised health care systems; and (vi) development of a globally interdependent education system to meet global health challenges. Examples of efforts being made to address these challenges are offered. Discussion Although strategies for combatting these challenges exist, the effectiveness of educational models depends on them being locally adaptable and applicable. Curricular reform must go hand‐in‐hand with research and evaluation to develop comprehensive futuristic models of teaching and learning that will adequately prepare health professionals to address the challenges.

AIM: The aim of this paper is to explore what might be gained from collecting and analysing visual data, such as photographs, scans, drawings, video and screen recordings, in clinical educational research. Its focus is on visual research that looks at teaching and learning ‘as it naturally occurs’ in the work place, in simulation centres and other sites, and also involves the collection and analysis of visual learning materials circulating in these sites. BACKGROUND: With the ubiquity of digital recording devices, video data and visual learning materials are now relatively cheap to collect. Compared to other domains of education research visual materials are not widely used in clinical education research. The paper sets out to identify and reflect on the possibilities for visual research using examples from an ethnographic study on surgical and inter-professional learning in the operating theatres of a London hospital. MAIN CONTRIBUTION: The paper shows how visual research enables recognition, analysis and critical evaluation of (1) the hidden curriculum, such as the meanings implied by embodied, visible actions of clinicians; (2) the ways in which clinical teachers design multimodal learning environments using a range of modes of communication available to them, combining, for instance, gesture and speech; (3) the informal assessment of clinical skills, and the intricate relation between trainee performance and supervisor feedback; (4) the potentialities and limitations of different visual learning materials, such as textbooks and videos, for representing medical knowledge. DISCUSSION AND CONCLUSION: The paper concludes with theoretical and methodological reflections on what can be made visible, and therefore available for analysis, explanation and evaluation if visual materials are used for clinical education research, and what remains unaccounted for if written language remains the dominant mode in the research cycle. Opportunities for quantitative analysis and ethical implications are also discussed.

Medical Education 2011:45: 867–877 OBJECTIVES Many medical schools are currently undergoing curriculum reform. When considering the means by which students will be evaluated in a revised curriculum, the need to reduce the prevalences of depression and anxiety associated with academic stress must be weighed against the importance of academic outcomes. Pass/fail evaluation, as compared with tiered grading, is commonly presented as a means to adequately assess student performance while minimising stress and anxiety. The purpose of this literature review was to determine the impact of pass/fail grading on medical student well-being and academic outcomes. METHODS A systematic search was performed of the available literature published between January 1980 and August 2010, using the PubMed, Ovid Medline, Ovid PsycINFO and ERIC databases. Eligible papers assessed the impact of pass/fail grading on medical student well-being, academic outcomes or both. Academic outcomes included but were not limited to objective measures, such as performance on the US Medical Licensing Examination, and subjective measures, such as student desirability by residency programmes. Reference lists in identified papers were searched and all identified papers were run through a citation index. RESULTS Four papers met the inclusion criteria for both well-being and academic outcomes. An additional five papers met the inclusion criteria for academic outcomes only. The four papers that focused on well-being reported improvement in specified areas. No significant difference was identified in any of the five papers examining objective academic outcomes or in those papers that examined the quality of residency programmes attained. Results from two studies suggested that some programme directors believe pass/fail grading creates disadvantages for students in attaining a residency, whereas a third study yielded mixed results about its impact on residency attainment. CONCLUSIONS Student well-being is enhanced and objective academic performance is not adversely affected by a pass/fail evaluation system, but students’ ability to obtain a desired residency programme may be hindered by individual programme directors’ preferences for tiered grading systems. There is an overall paucity of literature on this topic and additional study is needed.

CONTEXT Law is slowly emerging as a core subject area in medical education, alongside content on the ethical responsibilities of doctors to protect and promote patient health and well-being. Curriculum statements have begun to advise on core content and methods for organising teaching and assessment. However, no comprehensive overview of approaches to the delivery of this law curriculum has been undertaken. OBJECTIVES This paper reports an assessment of the nature and strength of the published evidence base for the teaching, learning and assessment of law in medical education. It also provides a thematic content overview from the best available literature on the teaching of law to medical students and on the assessment of their legal knowledge and skills. METHODS A systematic review of the evidence base was completed. Detailed scrutiny resulted in the inclusion of 31 empirical sources and 11 conceptual papers. The quality of the included material was assessed. RESULTS Significant gaps exist in the evidence base. Empirical studies of the teaching of law are characterised by insufficient sample sizes and a focus on individual study programmes. They rely on measures of student satisfaction and on evaluating short-term outcomes rather than assessing whether knowledge is retained and whether learning impacts on patient outcomes. Studies reveal a lack of coordination between pre- or non-clinical and clinical medico-legal education. Although evidence on the development of students' knowledge is available, much learning is distant from the practice in which its application would be tested. Law learning in clinical placements appears to be opportunistic rather than structured. CONCLUSIONS The place of law in the curriculum remains uncertain and should be more clearly identified. A more robust knowledge base is needed to realise the aspirations behind curriculum statements on law and to enable medical students to develop sufficient legal literacy to manage challenging practice encounters. Further research is needed into effective methods of teaching, learning and assessing legal knowledge and skills during and following initial medical education.

The Hollywood film Field of Dreams depicts a farmer who dreams of hosting professional baseball games on his land. As he walks through his fields of corn, a ghostly voice, referring to the farmer's imagined baseball field, the star player and the spectators who will consequently flock to the site, calls: ‘If you build it, he will come.’ As clinical educators, we make similar assumptions all the time. We want to do what is best for our learners. We assume that if we invest time, energy and money into developing an interactive and engaging curriculum, students will attend. Not only will they attend, but they will also have completed the pre-sessional tasks we have set them, and will focus on their learning during the session, abandoning the distractions of social media and their peers. Why wouldn't they do this? They want to be clinicians, so surely they recognise the need to come to teaching sessions and engage with faculty staff? We assume that if we invest time, energy and money into developing an interactive and engaging curriculum, students will attend. Unfortunately, the frank and honest paper by White et al.1 published in this issue of the journal, shows that our best efforts to produce a student-centred curriculum to encourage active learning and engagement can sometimes fail to deliver the experience we predicted. In this example of an obviously genuine attempt to deliver a modern new curriculum with a flipped classroom approach, student attendance dropped as low as 25%.1 It is easy to picture a faculty meeting at this institution, at which frustrated voices cite the wasting of resources and the pointless implementation of new methods of delivery. Why should we bother taking new approaches when students fail to fulfil their obligations as learners? Surely it would be sensible to retain the ‘safe option’ of didactic delivery? Why should we bother taking new approaches when students fail to fulfil their obligations as learners? Rather than allowing the effort put into making these changes to go to waste, White et al.1 have taken time to consider the reasons for this disengagement. Their conclusions are very useful: they suggest that students need better training to learn effectively this way, and that faculty development is also required. However, it is also essential to consider the culture in which this change was attempted. The learning culture has much to answer for when curricular changes are made. Although it is true that students entering undergraduate training may not be ready for a more ‘grown-up’ form of learning, and may not yet possess the self-direction and self-motivation they require for success, there may also be unseen influences that prevent successful delivery. Impressionable teenage learners, who have not yet learned the skills of adult learning, are not only exposed to the formal curriculum we deliver, but also to the unseen influences of peer role models and rituals within the hidden curriculum.2 These latter influences may pull them away from their core activities of study and learning, distracting them from their central focus of learning to be a clinician. A change in learning culture is therefore necessary in order to implement new teaching strategies such as those involved in the flipped classroom3 and, furthermore, both students and faculty members need help to engage effectively in this different culture. Impressionable teenage learners are not only exposed to the formal curriculum, but also to the unseen influences of peer role models and rituals within the hidden curriculum. Interestingly, the paper by White et al.1 notes the supportive nature of students' interactions with one another, which emerged strongly in student focus groups engaged in discussing the curriculum. Although this is an attribute we should encourage in students as a positive behaviour during the stage of proto-professionalism prior to their emerging as professionals,4 it does not in this context help their learning. As well as training students in active learning techniques, we should facilitate explicit discussion of the influence of the hidden curriculum as this will help students to understand how elements such as negative role models can influence their learning behaviours.5 Students should also be encouraged to reflect on their learning styles and abilities in order to develop as learners who continue to help each other whilst maintaining their focus on the information they are considering. They should be explicitly taught the process of reflection because this is a required attribute for success as a student in a curriculum that embraces active learning approaches.6 Reflective skills will also be necessary as an aspect of future professionalism and thus their development at a very early stage is extremely useful.7,8 Students should be encouraged to reflect on their learning styles and abilities in order to develop as learners. It is somewhat disappointing, perhaps, that the faculty staff referred to in this study1 did not consider the learning culture before investing time and money in a new curriculum. Whenever curricula are planned, faculty staff must perform a thorough needs assessment,9 which should include an analysis of teaching delivery aligned to learners' ability and faculty staff engagement. It is easy to read about initiatives such as that of flipping the classroom and start to embed them in a redesigned curriculum without considering issues such as learner readiness and institutional culture. New delivery methods such as this may have limited contextual evidence to show their effectiveness,3 but lessons learned from similar strategies involving active learning can certainly be drawn from. Problem-based learning curricula have certainly been well researched and there is plenty of evidence to show that their failure often derives from a lack of faculty readiness, student disengagement and the powerful influence of the hidden curriculum.10,11 It is easy to read about initiatives such as that of flipping the classroom and start to embed them in a redesigned curriculum without considering learner readiness and institutional culture. It is therefore important that curriculum designers reflect thoroughly on all aspects of institutional culture before implementing new and innovative teaching strategies. What works in one environment may be entirely ineffective in another context. Faculty staff must be mindful of the ‘curse of the teenage learner’ and must be ready to teach students to learn, as well as to recognise the influence of their peers as role models. Only then will active learning become embedded in the culture and practices of learning in an institution, and the hidden curriculum will become an ally rather than an enemy. Only then may the field of dreams become a reality for clinical educators.

OBJECTIVES Most basic medical education studies focus on one medical school, and the social and educational significance of differences between schools remains poorly understood. Sociologists have called for more comparative studies and for research on the institutional context of medical education. This paper introduces Bourdieu's concept of 'field' as a tool for conducting such analyses. CONTEXT A 'field' is any arena in which there is a struggle over resources (capital), akin to a 'game' between players who occupy different positions depending on the resources they have. Prior studies show that higher education institutions compete in a field for various forms of capital which are reflected in their curricula and the students they attract. METHODS This paper argues that medical education can be conceptualised as a field within which medical schools compete for different forms of capital, such as students, funding and prestige. The structure of the UK medical education field is analysed as a specific example of how Bourdieu's framework can be applied. It is argued that UK medical schools' varying curricula and admissions criteria serve to distinguish them from their competitors and to facilitate access to different forms of capital. Competition within the field helps to maintain inter-school differences, with implications for both curriculum reform and students' beliefs and aspirations. CONCLUSIONS Medical schools have varying curricula, reputations, and types and levels of resources. They compete with one another on all these fronts and attract different types of students and staff. Research and practice in basic medical education must take account of the position of any given medical school in relation to its competitors and to external agencies in order to critically consider the ethos of its curriculum and the perspectives of its students and staff. Bourdieu's concept of field offers one useful way of accomplishing this.

OBJECTIVES In an effort to provide preventive advice, this paper aims to acknowledge what has not worked with regard to cultural competency initiatives. A successful cultural competency training initiative should have lasting impact on its participants in terms of long-term, ideally permanent changes to attitudes, knowledge and skills resulting in the provision of optimum care, regardless of a patient's cultural background. Legal mandates mean there is an assumed need for cultural competency curricula and training programmes for medical students and postgraduate medical trainees. However, policy and practice have bypassed 'proof' that such programmes are effective and result in better patient care. Often only positive results are reported, which may minimise the difficulties involved in programme implementation. METHODS Utilising the example of a cultural competency initiative introduced into a postgraduate general surgery training programme, this paper discusses mistakes that were made during the implementation phase, particularly with regard to underestimating potential resistance by the trainees. Also presented are the lessons learned and efforts that were made to mitigate the problems that arose. None of what is discussed in this paper is new. However, the literature often does not discuss in detail the difficulties that can be or have been faced and how these obstacles can be adequately mitigated. CONCLUSIONS The glow of cultural competency training initiatives is fading in the light of higher expectations for an evidence base prior to acknowledgement that their introduction has had a positive impact. For these initiatives to advance, there needs to be a clear understanding of terms utilised, buy-in and a long-term commitment at both individual and organisational levels, and use of standardised and validated tools to measure outcomes. An understanding of potential pitfalls can help to advance cultural competency training to the next level, namely, a solid evidence base that justifies both an individual's and an institution's investment in this effort.

Context: The teaching and assessment of clinical communication have become central components of undergraduate medical education in the UK. This paper recommends the key content for an undergraduate communication curriculum. Designed by UK educationalists with UK schools in mind, the recommendations are equally applicable to communication curricula throughout the world. Objectives: This paper is intended to assist curriculum planners in the design, implementation and review of medical communication curricula. The document will also be useful in the education of other health care professionals. Designed for undergraduate education, the consensus statement also provides a baseline for further professional development. Methods: The consensus statement, based on strong theoretical and research evidence, was developed by an iterative process of discussion between communication skills leads from all 33 UK medical schools conducted under the auspices of the UK Council of Clinical Communication Skills Teaching in Undergraduate Medical Education. Discussion: How this framework is used will inevitably be at the discretion of each medical school and its implementation will be determined by different course designs. Although we believe students should be exposed to all the areas described, it would be impractical to set inflexible competency levels as these may be attained at different stages which are highly school-dependent. However, the framework will enable all schools to consider where different elements are addressed, where gaps exist and how to generate novel combinations of domains within the communication curriculum. It is hoped that this consensus statement will support the development and integration of teaching, learning and assessment of clinical communication. © Blackwell Publishing Ltd 2008.

Introduction Many doctors, across grades and specialities, supervise or advise students and juniors undertaking elective placements. Electives form part of medical curricula on a worldwide scale. The Medical Schools Council (MSC) Electives Committee in the UK identified a gap in the current literature in relation to provision of comprehensive recommendations for the design and management of undergraduate elective programmes. Electives afford many known benefits for medical and other health care students, but the context, and risks (impacting potentially on patient, public and student well-being) are usually different from those associated with ‘home’ clinical placements. Aim The aim is to share experiences and good practice within UK Medical Schools, and inform and inspire others involved with similar programmes across the globe. Method This paper reports the results of the formation of a sub-group to draft a set of recommendations, drawing on the reported experiences of academic elective leads across all UK schools, and including input from the MSC, and the student group Medsin (to capture the learner voice). The final document was the result of a national consultative process of four iterations. The end document was approved at school level, e.g. by curriculum committee, by each of the participating schools. Recommendations The recommendations consolidate the experiences of 30 participating UK medical schools. The consultation process generated 17 pre-departure recommendations, seven during elective recommendations, 11 post elective recommendations and a further four recommendations relating to infectious disease. Conclusion We believe developing elective programmes using collective recommendations will provide a basis for a safer and more structured approach to a medical elective without losing the uniqueness and creative experiences valued by participants. Issues relating to undergraduates leaving their home school to experience medicine in a new context or country replicate across sites, so many recommendations will be transferable internationally.

Context Basic science teaching in undergraduate medical education faces several challenges. One prominent discussion is focused on the relevance of biomedical knowledge to the development and integration of clinical knowledge. Although the value of basic science knowledge is generally emphasised, theoretical positions on the relative role of this knowledge and the optimal approach to its instruction differ. The present paper addresses whether and to what extent biomedical knowledge is related to the development of clinical knowledge. Methods We analysed repeated-measures data for performances on basic science and clinical knowledge assessments. A sample of 598 medical students on a traditional curriculum participated in the study. The entire study covered a developmental phase of 2 years of medical education. Structural equation modelling was used to analyse the temporal relationship between biomedical knowledge and the acquisition of clinical knowledge. Results At the point at which formal basic science education ends and clinical training begins, students show the highest levels of biomedical knowledge. The present data suggest a decline in basic science knowledge that is complemented by a growth in clinical knowledge. Statistical comparison of several structural equation models revealed that the model to best explain the data specified unidirectional relationships between earlier states of biomedical knowledge and subsequent changes in clinical knowledge. However, the parameter estimates indicate that this association is negative. Discussion Our analysis suggests a negative relationship between earlier levels of basic science knowledge and subsequent gains in clinical knowledge. We discuss the limitations of the present study, such as the educational context in which it was conducted and its non-experimental nature. Although the present results do not necessarily contradict the relevance of basic sciences, we speculate on mechanisms that might be related to our findings. We conclude that our results hint at possibly critical issues in basic science education that have been rarely addressed thus far.

Context For nearly 40 years, outcome-based models have dominated programme evaluation in health professions education. However, there is increasing recognition that these models cannot address the complexities of the health professions context and studies employing alternative evaluation approaches that are appearing in the literature. A similar paradigm shift occurred over 50 years ago in the broader discipline of programme evaluation. Understanding the development of contemporary paradigms within this field provides important insights to support the evolution of programme evaluation in the health professions. Methods In this discussion paper, we review the historical roots of programme evaluation as a discipline, demonstrating parallels with the dominant approach to evaluation in the health professions. In tracing the evolution of contemporary paradigms within this field, we demonstrate how their aim is not only to judge a programme’s merit or worth, but also to generate information for curriculum designers seeking to adapt programmes to evolving contexts, and researchers seeking to generate knowledge to inform the work of others. Discussion From this evolution, we distil seven essential elements of educational programmes that should be evaluated to achieve the stated goals. Our formulation is not a prescriptive method for conducting programme evaluation; rather, we use these elements as a guide for the development of a holistic ‘programme of evaluation’ that involves multiple stakeholders, uses a combination of available models and methods, and occurs throughout the life of a programme. Thus, these elements provide a roadmap for the programme evaluation process, which allows evaluators to move beyond asking whether a programme worked, to establishing how it worked, why it worked and what else happened. By engaging in this process, evaluators will generate a sound understanding of the relationships among programmes, the contexts in which they operate, and the outcomes that result from them.

Objectives: Given the absence of a common passing standard for students at UK medical schools, this paper compares independently set standards for common ‘one from five’ single-best-answer (multiple-choice) items used in graduation-level applied knowledge examinations and explores potential reasons for any differences.\ud \ud Methods: A repeated cross-sectional study was conducted. Participating schools were sent a common set of graduation-level items (55 in 2013–2014; 60 in 2014–2015). Items were selected against a blueprint and subjected to a quality review process. Each school employed its own standard-setting process for the common items. The primary outcome was the passing standard for the common items by each medical school set using the Angoff or Ebel methods.\ud \ud Results: Of 31 invited medical schools, 22 participated in 2013–2014 (71%) and 30 (97%) in 2014–2015. Schools used a mean of 49 and 53 common items in 2013–2014 and 2014–2015, respectively, representing around one-third of the items in the examinations in which they were embedded. Data from 19 (61%) and 26 (84%) schools, respectively, met the inclusion criteria for comparison of standards. There were statistically significant differences in the passing standards set by schools in both years (effect sizes (f2): 0.041 in 2013–2014 and 0.218 in 2014–2015; both p < 0.001). The interquartile range of standards was 5.7 percentage points in 2013–2014 and 6.5 percentage points in 2014–2015. There was a positive correlation between the relative standards set by schools in the 2 years (Pearson's r = 0.57, n = 18, p = 0.014). Time allowed per item, method of standard setting and timing of examination in the curriculum did not have a statistically significant impact on standards.\ud \ud Conclusions: Independently set standards for common single-best-answer items used in graduation-level examinations vary across UK medical schools. Further work to examine standard-setting processes in more detail is needed to help explain this variability and develop methods to reduce it.

Context: Figured Worlds is a socio-cultural theory drawing on Vygotskian and Bakhtinian traditions, which has been applied in research into the development of identities of both learners and teachers in the wider education literature. It is now being adopted in medical education.Objective: The objective of this paper is to show what Figured Worlds can offer in medical education. Having explained some of its central tenets, we apply it to an important tension in our field. Application: The assumption that there is a uniform ‘good doctor’ identity, which must be inculcated into medical students, underlies much of what medical educators do, and what our regulators enforce. While diversity is encouraged when students are selected for medical school, pressure to professionalise students creates a drive towards a standardised professional identity by graduation. Using excerpts from reflective pieces written by two junior medical students, we review the basic concepts of Figured Worlds and demonstrate how it can shed light on the implications of this tension. Taking a Bakhtinian approach to discourse, we show how Adam and Sarah develop their professional identities as they negotiate the multiple overlapping and competing ways of being a doctor which they encounter in the world of medical practice. Each demonstrates agency by ‘authoring’ a unique identity in the cultural world of medicine, as they appropriate and re-voice the words of others. Discussion: Finally, we consider some important areas in medical education where Figured Worlds might prove to be a useful lens: the negotiation of discourses of gender, sexuality and social class, career choice as identification within specialty-specific cultural worlds, and the influence of hidden and informal curricula on doctor identity.

Medical Education 2012: 46: 357-365 Context Current debate in medical education focuses on the nature of 'competency-based medical education' (CBME) and whether or not it should be adopted. Many medical schools claim to run 'competency-based' curricula, but the structure of their programmes can differ radically. A review of the existing CBME literature reveals that little attention has been paid to defining the concept of competence. A straightforward examination of what is meant by the term 'competence' is noticeably missing from the literature, despite its impact on medical training. Objectives This paper aims to illustrate the varying conceptions of 'competence' by comparing and contrasting definitions provided in the health sciences education literature and discussing their respective impacts on medical education. Methods A systematic review of recent publications in medical education journals published in English and French was conducted to extract definitions of competence or, if definitions were not explicitly stated, to derive the authors' implicit conception of competence. A sample of 14 definitions from articles in the health sciences education field was studied using thematic analysis. Results There is agreement that competence is composed of knowledge, skills and other components. Although agreement about the nature of these other components is lacking, attitudes and values are suggested to be essential ingredients of competence. Furthermore, a clear divergence in conceptions of how a competent person utilises these components is apparent. One view specifies that competence involves selecting components according to specific situations, as required. A second view places greater emphasis on the synergy that results from the use of a combination of components in a given situation. Conclusions These conceptual distinctions have many implications for the way CBME is implemented. A conception of competence as the selection of components may lead to a greater emphasis, in a training setting, on the mastery of each component separately. A conception of competence as the use of a combination of components leads to greater emphasis on the synergy that results as they are deployed in clinical situations.

CONTEXT Distributed medical education sites help train, recruit and retain doctors, notably in rural and isolated areas, by providing education and training in these areas and adapting their curriculum to meet the host community's health needs. OBJECTIVES The Centre de Formation Medicale du Nouveau Brunswick (CFMNB; New Brunswick Medical Education Centre) was established by a partnership between two academic institutions, the Universite de Sherbrooke (University of Sherbrooke), situated in the province of Quebec, and the Universite de Moncton (University of Moncton), situated in the province of New Brunswick, in Canada. The CFMNB is specifically targeting a minority community (Acadians). Working to establish a high-quality medical education programme, the CFMNB has also set community objectives to meet not only the health needs of this population, but also its social and economic needs. METHODS This paper describes the overall objectives of this project, which are: to reduce the gap between community needs and academic institutional needs; to address ethno-cultural and language differences in a defined minority population, and to develop collaboration between the partners involved, including government and community entities which are often perceived as operating in isolation from one another. We also describe why and how the CFMNB developed community-focused objectives and the challenges that came with these innovations, and present lessons from the experience that may be relevant to other sites interested in the social responsibility of medical schools. CONCLUSIONS The CFMNB has produced interesting work and innovations in the field of social responsibility and has encountered many challenges. Continuing interaction between medical education, health research and health services to better address the needs of the population has been established. The information obtained by this process has been used to build a strategic plan for the CFMNB in order to ensure that it is socially responsive and has significant generalisable features.

Summary The content of an undergraduate curriculum is usually decided upon by the appropriate University Department. Such a Department is staffed exclusively by specialists in the field. The technique described in this paper is one which uses the perception of a wide variety of doctors, including specialists in the field, other specialists and general practitioners, to determine what should be taught to undergraduate students. The outcome of this study reveals that there is substantial agreement on what basic materials should be taught in an undergraduate curriculum in Ophthalmology. There is a substantial agreement throughout the profession on the basic required competencies in Ophthalmology, but it is clear that general practitioners are much more demanding in their requirements from the undergraduate curriculum than are specialists. Ophthalmologists are the least demanding of the undergraduate. The consensus technique described in this paper is a practical and formative method of obtaining valuable data for use in curriculum construction.

Background Peer-assisted learning (PAL) is increasingly used in medical education, and the benefits of this approach have been reported. Previous reviews have focused on the benefits of peer tutoring of junior students by senior students. Forms of PAL such as discussion groups and role-playing have been neglected, as have alternative teacher-learner configurations (e.g. same-level PAL) and the effects on other stakeholders, including clinician educators and patients. This review examines the benefits of same-level PAL for students, clinician educators and patients in pre-registration clinical medical education. Methods Medline, PsycINFO, CINAHL and ERIC were searched in March 2014. A total of 1228 abstracts were retrieved for review; 64 full-text papers were assessed. Data were extracted from empirical studies describing a same-level PAL initiative in a clinical setting, focusing on effects beyond academic performance and student satisfaction. Qualitative thematic analysis was employed to identify types of PAL and to cluster the reported PAL effects. Results Forty-three studies were included in the review. PAL activities were categorised into role-play, discussion, teaching and assessment. Only 50% of studies reported information beyond self-report and satisfaction with the PAL intervention. Benefits for students (including development of communication and professional skills) and clinician educators (developing less-used facilitation skills) were reported. Direct patient outcomes were not identified. Caveats to the use of PAL emerged, and guidelines for the use of PAL were perceived as useful. Conclusion Many student-related benefits of PAL were identified. PAL contributes to the development of crucial skills required for a doctor in the workplace. Vertical integration of learning and teaching skills across the curriculum and tools such as feedback checklists may be required for successful PAL in the clinical environment. Benefits for patients and educators were poorly characterised within the included studies. Future work should evaluate the use of PAL with regards to student, clinician educator and patient outcomes.

Purpose Despite numerous calls for reform over several decades, medical educators have been unable to address many significant challenges. Potentially, employing new metaphors and looking at the teaching and learning of medicine in a new way will facilitate the development of creative solutions. Main findings In this paper we propose the metaphor of medicine as a performing art. Building on this metaphor, string music education is compared to medical education. Principal conclusions Looking to string education as a model, suggestions for reorganisation of learning experiences, academic structure and assessment are discussed. Medical educators are encouraged to think about the challenges they face in creative ways. By looking outside traditional medical education, solutions may be found to new and old educational dilemmas.

The current emphasis on providing quality undergraduate and postgraduate medical education has focused attention on the educational responsibilities of all doctors. There is a greater awareness of the need to train doctors as educators and courses have been set up to satisfy this need. Some courses, such as those on how to conduct appraisal, are specific to one task facing a medical educator. Other courses take a broader view and relate educational theory to practice. In this paper we describe an outcome-based approach in which competence in teaching is defined in terms of 12 learning outcomes. The framework provides a holistic approach to the roles of the teacher and supports the professionalism of teaching. Such a framework provides the basis for the development of a curriculum for teaching excellence. It helps to define important competences for different categories of teachers, communicate the areas to be addressed in a course, identify gaps in course provision, evaluate courses, assist in staff planning and allow individuals to assess their personal learning needs. The framework is presented to encourage wider debate.

SUMMARY This paper compares ethics programmes in clinical edu­ cation in two medical schools in the Netherlands. Ethics education in the University of Maastricht is case ori­ ented, whereas the emphasis in ethics teaching in the Catholic University of Nijmegen is focused on the meth­ ods of ethics and moral reasoning. The general objec­ tives, format and evaluation are discussed. Both pro­ grammes assume that in clinical decision-making normative and technical issues are intertwined; if a nor­ mative dimension is intrinsic to medical practice itself, students should learn during clinical training how to explicate and evaluate the moral quandaries of their pro­ fession. The positive characteristics of the Maastricht programme (student-centred approach, relevant cases, team-teaching of ethicist and clinician), if combined with those of the Nijmegen programme (a coherent theo­ retical framework and method for case analysis and inter­ pretation), would create a new, powerful model for clini­ cal ethics teaching. In a recent report such a model is advocated for all Dutch medical schools.

promotions process. What was done We conducted an online survey of 294 clinician-educators and a paper-based survey of 17 department chairs to define current portfolio practices at our institution. After a literature review and an informal survey of practices at other institutions, we created a template for the educator’s portfolio and an assessment tool for portfolio evaluation. We presented our work to the dean of the School of Medicine and the chairpersons of the clinical departments at our institution. We conducted a lecture at a workshop for new faculty members and presented a separate half-day faculty development workshop on the educator’s portfolio, during which we disseminated the template, provided guidance regarding the development and evaluation process, and provided education on key aspects of effective portfolios, including writing an effective teaching philosophy statement and demonstrating educational scholarship. Evaluation of results and impact Ten of 17 clinical departments responded to the survey; only two of these departments had formal portfolio development guidelines in place and none had formal evaluation criteria. A total of 125 faculty members participated in the survey (response rate 43%); 48% of these respondents did not know the difference between an educator’s portfolio and a promotions packet, and 86% had not received any formal information from their departments regarding portfolio development or the evaluation process. Fifty-five people attended the half-day faculty development workshop, the largest attendance ever recorded at a faculty development workshop at our institution. All attendees received a binder with the portfolio template and detailed instructions about the information to be included in each section and the best means for presenting that information. Attendees completed evaluations of the workshop and gave it an overall score of 4.7 (0 = lowest, 5 = highest). The workshop also received high scores for clarity of content (4.67), organisation (4.67) and relevance of content to clinician-educators (4.73). A formal committee evaluating the promotions process at our institution has incorporated our template into its specific recommendations to the dean of the School of Medicine at our institution.

BACKGROUND: A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learner's evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualize a dynamic awareness of prevailing risk and the implications of moving between zones. THE IMPORTANCE OF CONTEXT: We argue that clinical exposure can be consolidated by simulation where appropriate, ensuring that each learner gains the skills for safe care within the increasingly limited time available for training. To be effective, however, such simulation must be realistic, patient-focused, structured and grounded in an authentic clinical context. Challenge comes not only from technical difficulty but also from the need for interpersonal skills and professionalism within clinical encounters. PATIENT FOCUSED SIMULATION: Many existing simulations focus on crises, so clinicians are in a heightened state of expectation that may not reflect their usual practice. We argue that simulation should also reflect commonly occurring non-crisis situations, allowing clinicians to develop an awareness of the complex events that underpin clinical encounters. We describe a patient-focused approach to simulation, using simulated patients and inanimate models within realistic scenarios, to ground experience in authentic clinical practice and bring together the complex elements that underpin clinical events. APPLICATIONS: Although our argument has evolved from surgical practice and operating theatre teams, we believe it can be widely applied to the increasing number of health care professionals who perform clinical interventions.

Career choice, sense of professional identity and career behaviour are influenced, subject to change and capable of development through interaction with the learning environment. In this paper workplace learning discourses are used to frame ongoing concerns associated with higher specialist training. Data from the first stage of a multimethods investigation into recruitment into and retention in specialties in the West Midlands is used to consider some possible effects of the specialist learning environment on recruitment and retention.The aim of the study was to identify issues, through interviews with 6 consultants and questionnaires completed by specialist registrars from specialties representing a range of recruitment levels. These would inform subsequent study of attributes and dispositions relevant to specialist practice and recruitment. The data were analysed using NVivo software for qualitative data management.Participants' perceptions are presented as bipolar dimensions, associated with: curriculum structure, learning relationships, assessment of learning, and learning climate. They demonstrate ongoing struggle between different models of workplace learning.Changes in the postgraduate education of doctors seem set to continue well into the future. How these are reflected in the balance between workplace learning models, and how they influence doctors' sense of identity as specialists suggests a useful basis for examination of career satisfaction and recruitment to specialties.