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Introduction Healthcare systems require healthcare professionals and students educated in an interprofessional (IP) context. Well-designed assessments are needed to evaluate whether students have developed IP competencies, but we currently lack evidence-informed guidelines to create them. This study aims to provide guidelines for the assessment of IP competencies in healthcare education. Methods A qualitative consensus study was conducted to establish guidelines for the design of IP assessments using the nominal group technique. First, five expert groups (IP experts, patients, educational scientists, teachers, and students) were asked to discuss design guidelines for IP assessment and reach intra-group consensus. Second, one heterogeneous inter-group meeting was organized to reach a consensus among the expert groups on IP assessment guidelines. Results This study yielded a comprehensive set of 26 guidelines to help design performance assessments for IP education: ten guidelines for both the IP assessment tasks and the IP assessors and six guidelines for the IP assessment procedures. Discussion The results showed that IP assessment is complex and, compared to mono-professional assessment, high-quality IP assessments require additional elements such as multiple IP products and processes to be assessed, an IP pool of assessors, and assessment procedures in which standards are included for the IP collaboration process as well as individual contributions. The guidelines are based on expert knowledge and experience, but an important next step is to test these design guidelines in educational practice.

Introduction Increasingly medical students pursue medical education abroad. Graduates from International Medical Programs (IMPs) practice globally, yet how to prepare students for an unknown international environment is complex. Following IMP graduates throughout their early careers, this study offers insights into gaps in current undergraduate education. Methods In this international, longitudinal, mixed-methods study, 188 graduates from seven IMPs completed baseline surveys on career choice and job preparedness. Forty-two participants completed follow-up until three years after graduation. Nine graduates participated in semi-structured interviews on individual experiences and the evolution of their perspectives. The multiphase, sequential design allowed data collected at baseline to inform further data collection instruments. Results Two typical student profiles emerged. The first depicts a student who, despite the challenges of studying abroad, pursues a medical degree 'anyhow', with a common aim of practicing in their home country. The other deliberately selects an IMP while envisaging an international career. Two years after graduation, the majority (> 70%) of our participants were practicing in a country other than their country of training. They reported challenges around licensing, the job application process and health system familiarization. Participants' experiences point towards potential curriculum adaptations to facilitate cross-border transitions, including career guidance, networking and entrance exam preparation. Discussion IMP graduates lack support in practical aspects of career orientation and international exposure. Most IMPs essentially prepare their graduates for a career elsewhere. Gaps and challenges that IMP graduates experience in this cross-border career transition entail a responsibility for preparation and guidance that is currently lacking in IMP curricula.

Introduction For several decades, educational experts have promoted reflection as essential to professional development. In the medical setting, collaborative reflection has gained significant importance across the curriculum. Collaborative reflection has a unique edge over individual reflection, but many medical teachers find facilitating group reflection sessions challenging and there is little documentation about the didactics of teaching in such collaborative reflection settings. To address this knowledge gap, we aim to capture the professional knowledge base for facilitating collaborative reflection by analyzing the formal and perceived goals and strategies of this practice. Methods The professional knowledge base consists of formal curricular materials as well as individual teacher expertise. Using Template Analysis, we analyzed the goals and strategies of collaborative reflection reported in institutional training documents and video-stimulated interviews with individual teachers across all Dutch general practitioner training institutes. Results The analysis resulted in a highly diverse overview of educational goals for residents during the sessions, teacher goals that contribute to those educational goals, and a myriad of situation-specific teacher strategies to accomplish both types of goals. Teachers reported that the main educational goal was for residents to learn and develop and that the teachers’ main goal was to facilitate learning and development by ensuring everyone’s participation in reflection. Key teacher strategies to that end were to manage participation, to ensure a safe learning environment, and to create conditions for learning. Discussion The variety of strategies and goals that constitute the professional knowledge base for facilitating collaborative reflection in postgraduate medical education shows how diverse and situation-dependent such facilitation can be. Our analysis identifies a repertoire of tools that both novice and experienced teachers can use to develop their professional skill in facilitating collaborative reflection. Supplementary Information The online version of this article (10.1007/s40037-021-00677-6) contains supplementary material, which is available to authorized users.

Introduction Health professions educators risk misunderstandings where terms and concepts are not clearly defined, hampering the field’s progress. This risk is especially pronounced with ambiguity in describing roles. This study explores the variety of terms used by researchers and educators to describe “faculty”, with the aim to facilitate definitional clarity, and create a shared terminology and approach to describing this term. Methods The authors analyzed journal article abstracts to identify the specific words and phrases used to describe individuals or groups of people referred to as faculty. To identify abstracts, PubMed articles indexed with the Medical Subject Heading “faculty” published between 2007 and 2017 were retrieved. Authors iteratively extracted data and used content analysis to identify patterns and themes. Results A total of 5,436 citations were retrieved, of which 3,354 were deemed eligible. Based on a sample of 594 abstracts (17.7%), we found 279 unique terms. The most commonly used terms accounted for approximately one-third of the sample and included faculty or faculty member/s (n = 252; 26.4%); teacher/s (n = 59; 6.2%) and medical educator/s (n = 26; 2.7%) were also well represented. Content analysis highlighted that the different descriptors authors used referred to four role types: healthcare (e.g., doctor, physician), education (e.g., educator, teacher), academia (e.g., professor), and/or relationship to the learner (e.g., mentor). Discussion Faculty are described using a wide variety of terms, which can be linked to four role descriptions. The authors propose a template for researchers and educators who want to refer to faculty in their papers. This is important to advance the field and increase readers’ assessment of transferability. Supplementary Information The online version of this article (10.1007/s40037-021-00683-8) contains supplementary material, which is available to authorized users.

Introduction Communication training with simulated patients (SPs) is widely accepted as a valuable and effective means of teaching communication skills. However, it is unclear which elements within SP-student encounters make these learning experiences meaningful. This study focuses on the SP’s role during meaningful learning of the student by giving an in-depth understanding of the contribution of the SP from a student perspective. Methods Fifteen bachelor Technical Medicine students were interviewed. Technical medicine students become technical physicians who optimize individual patient care through the use of personalized technology. Their perceptions of meaningful learning experiences during SP-student encounters were explored through in-depth, semi-structured interviews, and analyzed using thematic analysis. Results Three main themes were identified that described what students considered to be important for meaningful learning experiences. First, SPs provide implicit feedback-in-action. Through this, students received an impression of their communication during the encounter. Implicit feedback-in-action was perceived as an authentic reaction of the SPs. Second, implicit feedback-in-action could lead to a process of reflection-in-action, meaning that students reflect on their own actions during the consultation. Third, interactions with SPs contributed to students’ identity development, enabling them to know themselves on a professional and personal level. Discussion During SP encounters, students learn more than just communication skills; the interaction with SPs contributes to their professional and personal identity development. Primarily, the authentic response of an SP during the interaction provides students an understanding of how well they communicate. This raises issues whether standardizing SPs might limit opportunities for meaningful learning. Supplementary Information The online version of this article (10.1007/s40037-021-00684-7) contains supplementary material, which is available to authorized users.

Introduction Health professions education faces transitions from monodisciplinary to integrated education and from soloist teachers to interdisciplinary teacher teams. Interdisciplinary teamwork has been found complex and prone to conflict. Teachers’ perceptions of why some teams work and learn as a real interdisciplinary team and others do not are lacking in this setting. We studied the factors that teachers perceive as enabling and/or inhibiting interdisciplinary team learning. Methods In this exploratory, qualitative study, we conducted 17 semi-structured, vignette-guided interviews with teachers recruited from diverse disciplines in undergraduate health professions programmes at Maastricht University, the Netherlands, through maximum variation sampling. Team learning research informed data collection and template analysis. Results We identified three themes representing the factors that teachers perceived to influence interdisciplinary team learning: ‘alignment/misalignment with the educational philosophy’ (regarding personal attributes, tendencies and motivation), ‘leadership practices’ (encompassing team vision, responsibility and reflection), and ‘involvement in organisational processes’ (covering organisational decision-making, support and learning opportunities). For interdisciplinary team learning in development of integrated education, teachers emphasised their personal ability to move beyond disciplinary boundaries. Shared team leadership enabled the creation of a shared vision, shared responsibility, and team reflection. Lastly, teacher involvement in educational management, peer support and learning was considered important. Discussion To work beyond disciplines in health professions education, teachers should take an interest in integrated education, share responsibility and work in an environment where people continuously learn from others. Organisations can facilitate this by involving teachers in decision-making processes and providing faculty development aimed to foster shared leadership and team reflection. Supplementary Information The online version of this article (10.1007/s40037-020-00644-7) contains supplementary material, which is available to authorized users.

Introduction Portfolio-based assessments require that learners’ competence development is adequately reflected in portfolio documentation. This study explored how students select and document performance data in their portfolios and how they perceive these data to be representative for their competence development. Methods Students uploaded performance data in a competency-based portfolio. During one clerkship period, twelve students also recorded an audio diary in which they reflected on experiences and feedback that they perceived to be indicants of their competence development. Afterwards, these students were interviewed to explore the extent to which the performance documentation in the portfolio corresponded with what they considered illustrative evidence of their development. The interviews were analyzed using thematic analysis. Results Portfolios provide an accurate but fragmented picture of student development. Portfolio documentation was influenced by tensions between learning and assessment, student beliefs about the goal of portfolios, student performance evaluation strategies, the learning environment and portfolio structure. Discussion This study confirms the importance of taking student perceptions into account when implementing a competency-based portfolio. Students would benefit from coaching on how to select meaningful experiences and performance data for documentation in their portfolios. Flexibility in portfolio structure and requirements is essential to ensure optimal fit between students’ experienced competence development and portfolio content. Electronic supplementary material The online version of this article (10.1007/s40037-020-00571-7) contains supplementary material, which is available to authorized users.

Introduction Recent conceptualizations of self-regulated learning acknowledge the importance of co-regulation, i.e., students’ interactions with others in their networks to support self-regulation. Using a social network approach, the aim of this study is to explore relationships between characteristics of medical students’ co-regulatory networks, perceived learning opportunities, and self-regulated learning. Methods The authors surveyed 403 undergraduate medical students during their clinical clerkships (response rate 65.5%). Using multiple regression analysis, structural equation modelling techniques, and analysis of variance, the authors explored relationships between co-regulatory network characteristics (network size, network diversity, and interaction frequency), students’ perceptions of learning opportunities in the workplace setting, and self-reported self-regulated learning. Results Across all clerkships, data showed positive relationships between tie strength and self-regulated learning (β = 0.095, p

Introduction In postgraduate medical education, group decision-making has emerged as an essential tool to evaluate the clinical progress of residents. Clinical competency committees (CCCs) have been set up to ensure informed decision-making and provide feedback regarding performance of residents. Despite this important task, it remains unclear how CCCs actually function in practice and how their performance should be evaluated. Methods In the prototyping phase of a design-based approach, a CCC meeting was developed, using three theoretical design principles: (1) data from multiple assessment tools and multiple perspectives, (2) a shared mental model and (3) structured discussions. The meetings were held in a university children’s hospital and evaluated using observations, interviews with CCC members and an open-ended questionnaire among residents. Results The structured discussions during the meetings provided a broad outline of resident performance, including identification of problematic and excellent residents. A shared mental model about the assessment criteria had developed over time. Residents were not always satisfied with the feedback they received after the meeting. Feedback that had been provided to a resident after the first CCC meeting was not addressed in the second meeting. Discussion The principles that were used to design the CCC meeting were feasible in practice. Structured discussions, based on data from multiple assessment tools and multiple perspectives, provided a broad outline of resident performance. Residency programs that wish to implement CCCs can build on our design principles and adjust the prototype to their particular context. When running a CCC, it is important to consider feedback that has been provided to a resident after the previous meeting and to evaluate whether it has improved the resident’s performance. Electronic supplementary material The online version of this article (10.1007/s40037-018-0490-1) contains supplementary material, which is available to authorized users.

Introduction Behaviour is visible in real-life events, but also on social media. While some national medical organizations have published social media guidelines, the number of studies on professional social media use in medical education is limited. This study aims to explore social media use among medical students, residents and medical specialists. Methods An anonymous, online survey was sent to 3844 medical students at two Dutch medical schools, 828 residents and 426 medical specialists. Quantitative, descriptive data analysis regarding demographic data, yes/no questions and Likert scale questions were performed using SPSS. Qualitative data analysis was performed iteratively, independently by two researchers applying the principles of constant comparison, open and axial coding until consensus was reached. Results Overall response rate was 24.8%. Facebook was most popular among medical students and residents; LinkedIn was most popular among medical specialists. Personal pictures and/or information about themselves on social media that were perceived as unprofessional were reported by 31.3% of students, 19.7% of residents and 4.1% of medical specialists. Information and pictures related to alcohol abuse, partying, clinical work or of a sexually suggestive character were considered inappropriate. Addressing colleagues about their unprofessional posts was perceived to be mainly dependent on the nature and hierarchy of the interprofessional relation. Discussion There is a widespread perception that the presence of unprofessional information on social media among the participants and their colleagues is a common occurrence. Medical educators should create awareness of the risks of unprofessional (online) behaviour among healthcare professionals, as well as the necessity and ways of addressing colleagues in case of such lapses. Supplementary Information The online version of this article (10.1007/s40037-021-00660-1) contains supplementary material, which is available to authorized users.

Introduction Studies have shown that a physician’s clinical reasoning performance can be influenced by contextual factors. We explored how the clinical reasoning performance of medical students was impacted by contextual factors in order to expand upon previous findings in resident and board certified physicians. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of medical students in order to describe what impact the presence of contextual factors has on their reasoning performance. Methods Seventeen medical student participants viewed three video recordings of clinical encounters portraying straightforward diagnostic cases in internal medicine with explicit contextual factors inserted. Participants completed a computerized post-encounter form as well as a think-aloud protocol. Three authors analyzed verbatim transcripts from the think-aloud protocols using a constant comparative approach. After iterative coding, utterances were analyzed and grouped into categories and themes. Results Six categories and ten associated themes emerged, which demonstrated overlap with findings from previous studies in resident and attending physicians. Four overlapping categories included emotional disturbances, behavioural inferences about the patient, doctor-patient relationship, and difficulty with closure. Two new categories emerged to include anchoring and misinterpretation of data. Discussion The presence of contextual factors appeared to impact clinical reasoning performance in medical students. The data suggest that a contextual factor can be innate to the clinical scenario, consistent with situated cognition theory. These findings build upon our understanding of clinical reasoning performance from both a theoretical and practical perspective.

Introduction Creativity and improvisation are recognized as important aspects of training expertise in domains such as business and the arts, yet rarely discussed in medical education. This article examines how creativity and improvisation play out in the ways teachers give ‘expressive instructions’ to medical students when teaching physical skills. Methods Ethnographic fieldwork was conducted in a medical school in Maastricht, the Netherlands, with first, second and third year students learning physical examination skills. Over 230 h of fieldwork was conducted in the Skills Lab, including 34 tutorials of 1.5 h duration, with 11 different teachers and over 500 students. Patterns found in the fieldnotes were thematically analyzed using an inductive approach, drawing on sociological theories of craftsmanship. Results Findings showed that teachers improvise beyond the standardized lesson structure and classroom set-up, giving what we call, drawing on sociological theory, ‘expressive instructions’. This was visible in two main ways: 1) by teachers using their own bodies; 2) by teachers using materials that came to hand. Discussion This research highlights the important yet underexplored role of creativity and improvisation in teaching physical skills. Creativity and improvisation appear to be particularly important when training expertise in skills that are difficult to articulate and thus require expressive instructions, due for example to their sensory nature. Focusing on how expressive instructions play out in medical education offers insights into the tacit components of expertise development, a process which builds upon a long period of teachers’ skilled practice. Electronic supplementary material The online version of this article (10.1007/s40037-018-0446-5) contains supplementary material, which is available to authorized users.

Aim To investigate whether the current, generally accepted practice of orthopaedic surgical skills training can raise the performance of supervised residents to levels equal to those of experienced orthopaedic surgeons when it comes to clinical outcomes or implant position after total knee arthroplasty. Methods In a retrospective analysis of primary total knee arthroplasty outcomes (minimum follow-up of 12 months) procedures were split into two groups: supervised orthopaedic residents as first surgeon (group R), and experienced senior orthopaedic surgeons as first surgeon (group S). Outcome data that were compared 1 year postoperatively were operation times, complications, revisions, Knee Society Scores (KSS) and radiological implant positions. Results Of 642 included procedures, 220 were assigned to group R and 422 to group S. No statistically significant differences between the two groups were found in patient demographics. Operation time differed significantly (group R: 81.3 min vs. group S: 71.3 min (p = 0.000)). No statistically significant differences were found for complications (p = 0.659), revision rate (p = 0.722), femoral angle (p = 0.871), tibial angle (p = 0.804), femoral slope (p = 0.779), tibial slope (p = 0.765) and KSS (p = 0.148). Discussion and conclusion Supervised residents needed 10 minutes extra operation time, but they provided the same quality of care in primary total knee arthroplasty as experienced orthopaedic surgeons concerning complication rates, revisions, implant position on radiographs and KSS. The currently used training procedure in which the supervising surgeon and the resident decide if the resident is ready to be first surgeon is safe for patients.

‘How to know what others know?’ is a pertinent question debated extensively in education [1]. The tacit knowledge of professionals, the seldom expressed knowledge that guides professional practice [2, 3], has received particularly ample attention [4] for good reason. Explicating tacit knowledge can aid professionalization in several ways: it can improve performance by encouraging professionals to reflect on their behaviour; it can help communicate knowledge to others; it can facilitate evaluation by linking aspects of behaviour to outcomes of that behaviour; and finally it can aid construction of ‘artefacts’ that can assist in daily practice [5]. Each of these benefits underscores the exigency of explicating the tacit knowledge of professionals, e. g., practitioners (whether or not in training) and teachers in the field of medical education (cf. [6]). But how to elicit the tacit knowledge that informs professional practice? Mainstream research tools such as surveys and formal interviews, though employed extensively, are limited with respect to eliciting tacit knowledge. Formal interview questions such as ‘What do you aim for in your teaching?’ might be too abstract to answer and difficult to address given that they concern understandings that may rarely get expressed [7]. It has been argued that we need elicitation techniques that prompt participants to express their tacit knowledge by displaying the focus of interviews onto external stimuli, either visual, verbal, or written [7, 8]. These stimuli can facilitate the articulation of complex ideas in the participant’s own conceptual categories, bringing to the fore understandings that would otherwise remain below the surface [7]. Despite their clear value, however, many elicitation techniques use stimuli that are only distantly related to actual practice (e. g. photo elicitation, drawings) or interfere with the very practices that are under investigation (e. g. think-aloud protocols) [7, 9]. Video-stimulated interviewing [10] (VSI, also known as video elicitation interviewing [11]) is a promising exception that avoids both disadvantages by having participants view a video of their own behaviour while being asked questions about the recorded situation [12]. As such, VSI is a promising tool for eliciting the tacit knowledge that informs professional practice, provided that, as we argue in this paper, the tool is used to stimulate reflection, not recall. Historically, VSI has been used to elicit accounts of participants’ thinking at the time of recording (hence the frequent mentions of the tool as video-stimulated recall interviewing) [7]. Notwithstanding its potential value to other research purposes, this approach to VSI is problematic in research aimed at eliciting tacit knowledge. Indeed, we argue, a reflective approach to VSI is more productive to that aim. In the following, we first place both approaches in historical context to show their distinct epistemological roots. We then explain why recall VSI is less suited to uncovering tacit knowledge and why reflective VSI is better suited to do so, drawing on research outside of medical education, the few examples of reflective VSI in medical education, and from our own experience. Finally, we discuss several challenges and best practices of reflective VSI. This will help researchers to unleash the potential of reflective VSI in their own medical educational research, facilitating the search for answers to pressing issues that will aid progress in research and benefit implementation.

Introduction High-quality residency training is of utmost importance for residents to become competent medical specialists. Hospital-wide education committees have been adopted by several healthcare systems to govern postgraduate medical education and to support continuous quality improvement of residency training. To understand the functioning and potential of such committees, this study examined the mechanisms through which hospital-wide education committees strive to enable continuous quality improvement in residency training. Methods Focus group studies with a constructivist grounded theory approach were performed between April 2015 and August 2016. A purposeful sample of hospital-wide education committees led to seven focus groups. Results Hospital-wide education committees strived to enable continuous quality improvement of residency training by the following mechanisms: creating an organization-wide quality culture, an organization-wide quality structure and by collaborating with external stakeholders. However, the committees were first and foremost eager to claim a strategic position within the organization they represent. All identified mechanisms were interdependent and ongoing. Discussion From a governance perspective, the position of hospital-wide education committees in the Netherlands is uniquely contributing to the call for institutional accountability for the quality of residency training. When implementing hospital-wide education committees, shared responsibility of the committees and the departments that actually provide residency training should be addressed. Although committees vary in the strategies they use to impact continuous quality improvement of residency training, they increasingly have the ability to undertake supporting actions and are working step by step to contribute to high-quality postgraduate medical education.

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The overall purpose of the 'Statistical Points and Pitfalls' series is to help readers and researchers alike increase awareness of how to use statistics and why/how we fall into inappropriate choices or interpretations. We hope to help readers understand common misconceptions and give clear guidance on how to avoid common pitfalls by offering simple tips to improve your reporting of quantitative research findings. Each entry discusses a commonly encountered inappropriate practice and alternatives from a pragmatic perspective with minimal mathematics involved. We encourage readers to share comments on or suggestions for this section on Twitter, using the hashtag: #mededstatsUsing tools for statistical analysis that do not match with the design of the study increases the chance that conclusions drawn from that analysis are incorrect. Through a concise example of how failing to account for study design characteristics in the statistical analysis can result in incorrect conclusions with regard to specific comparisons of interest, this entry illustrates that key characteristics of the study design should drive choices at the stage of analysis.

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One area in which medical students can add significant value is medical education, and involving them as key stakeholders in their education can have a profound impact on students and the institutions that serve them. However, detailed descriptions of the structure, implementation and quality of programs facilitating student engagement are lacking. We describe the structure of a novel student engagement program at the University of Illinois College of Medicine-Chicago (UICOM-Chicago) known as the Student Curricular Board (SCB). We surveyed 563 medical students across all levels of training at our institution in order to examine the impact of this program, including its strengths and potential areas of improvement. The SCB serves as a highly structured and collaborative student group that has far-reaching involvement from course-level program evaluation to longitudinal curriculum design. Medical students overwhelmingly valued opportunities to be involved in their curriculum. Students with the greatest exposure to the SCB were more aware of specific program initiatives and expressed increased interest in academic medicine as a career. By highlighting this innovative student engagement program, we aim to share best practices for a highly structured, value-added approach to medical student engagement in medical education that is applicable to other medical schools and student leaders.

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Contains fulltext : 196801.pdf (Publisher’s version ) (Open Access) This paper discusses the advantages of progress testing. A utopia is described where medical schools would work together to develop and administer progress testing. This would lead to a significant reduction of cost, an increase in the quality of measurement and phenomenal feedback to learner and school. Progress testing would also provide more freedom and resources for more creative in-school assessment. It would be an educationally attractive alternative for the creation of cognitive licensing exams. A utopia is always far away in the future, but by formulating a vision for that future we may engage in discussions on how to get there.

Introduction Engaging in scientific misconduct and questionable research practices (QRPs) is a noted problem across fields, including health professions education (HPE). To mitigate these practices, other disciplines have enacted strategies based on researcher characteristics and practice factors. Thus, to inform HPE, this study seeks to determine which researcher characteristics and practice factors, if any, might explain the frequency of irresponsible research practices.Method In 2017, a cross-sectional survey of HPE researchers was conducted. The survey included 66 items adapted from three published surveys: two published QRP surveys and a publication pressure scale. The outcome variable was a self-reported misconduct score, which is a weighted mean score for each respondent on all misconduct and QRP items. Statistical analysis included descriptive statistics, reliability and correlation analysis, and multiple linear regression modelling.Results and Discussion In total, 590 researchers completed the survey. Results from the final regression model indicated that researcher age had a negative association with the misconduct score (b = -0.01, beta = -0.22, t = -2.91, p

Contains fulltext : 172025.pdf (Publisher’s version ) (Open Access) INTRODUCTION: Clinical encounters are often assessed using a checklist. However, without direct faculty observation, the timing and sequence of questions are not captured. We theorized that the sequence of questions can be captured and measured using coherence scores that may distinguish between low and high performing candidates. METHODS: A logical sequence of key features was determined using the standard case checklist for an observed structured clinical exam (OSCE). An independent clinician educator reviewed each encounter to provide a global rating. Coherence scores were calculated based on question sequence. These scores were compared with global ratings and checklist scores. RESULTS: Coherence scores were positively correlated to checklist scores and to global ratings, and these correlations increased as global ratings improved. Coherence scores explained more of the variance in student performance as global ratings improved. DISCUSSION: Logically structured question sequences may indicate a higher performing student, and this information is often lost when using only overall checklist scores. CONCLUSIONS: The sequence test takers ask questions can be accurately recorded, and is correlated to checklist scores and to global ratings. The sequence of questions during a clinical encounter is not captured by traditional checklist scoring, and may represent an important dimension of performance.

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Introduction Competency-based education (CBE) is now pervasive in health professions education. A foundational principle of CBE is to assess and identify the progression of competency development in students over time. It has been argued that a programmatic approach to assessment in CBE maximizes student learning. The aim of this study is to investigate if programmatic assessment, i. e., a system of assessment, can be used within a CBE framework to track progression of student learning within and across competencies over time. Methods Three workplace-based assessment methods were used to measure the same seven competency domains. We performed a retrospective quantitative analysis of 327,974 assessment data points from 16,575 completed assessment forms from 962 students over 124 weeks using both descriptive (visualization) and modelling (inferential) analyses. This included multilevel random coefficient modelling and generalizability theory. Results Random coefficient modelling indicated that variance due to differences in inter-student performance was highest (40%). The reliability coefficients of scores from assessment methods ranged from 0.86 to 0.90. Method and competency variance components were in the small-to-moderate range. Discussion The current validation evidence provides cause for optimism regarding the explicit development and implementation of a program of assessment within CBE. The majority of the variance in scores appears to be student-related and reliable, supporting the psychometric properties as well as both formative and summative score applications.

Introduction The guidelines offered in this paper aim to amalgamate the literature on formative feedback into practical Do’s, Don’ts and Don’t Knows for individual clinical supervisors and for the institutions that support clinical learning. Methods The authors built consensus by an iterative process. Do’s and Don’ts were proposed based on authors’ individual teaching experience and awareness of the literature, and the amalgamated set of guidelines were then refined by all authors and the evidence was summarized for each guideline. Don’t Knows were identified as being important questions to this international group of educators which if answered would change practice. The criteria for inclusion of evidence for these guidelines were not those of a systematic review, so indicators of strength of these recommendations were developed which combine the evidence with the authors’ consensus. Results A set of 32 Do and Don’t guidelines with the important Don’t Knows was compiled along with a summary of the evidence for each. These are divided into guidelines for the individual clinical supervisor giving feedback to their trainee (recommendations about both the process and the content of feedback) and guidelines for the learning culture (what elements of learning culture support the exchange of meaningful feedback, and what elements constrain it?) Conclusion Feedback is not easy to get right, but it is essential to learning in medicine, and there is a wealth of evidence supporting the Do’s and warning against the Don’ts. Further research into the critical Don’t Knows of feedback is required. A new definition is offered: Helpful feedback is a supportive conversation that clarifies the trainee’s awareness of their developing competencies, enhances their self-efficacy for making progress, challenges them to set objectives for improvement, and facilitates their development of strategies to enable that improvement to occur. Electronic supplementary material The online version of this article (doi: 10.1007/s40037-015-0231-7) contains supplementary material, which is available to authorized users.

Cognitive Load Theory (CLT) has started to find more applications in medical education research. Unfortunately, misconceptions such as lower cognitive load always being beneficial to learning and the continued use of dated concepts and methods can result in improper applications of CLT principles in medical education design and research. This review outlines how CLT has evolved and presents a synthesis of current-day CLT principles in a holistic model for medical education design. This model distinguishes three dimensions: task fidelity: from literature (lowest) through simulated patients to real patients (highest); task complexity: the number of information elements; and instructional support: from worked examples (highest) through completion tasks to autonomous task performance (lowest). These three dimensions together constitute three steps to proficient learning: (I) start with high support on low-fidelity low-complexity tasks and gradually fade that support as learners become more proficient; (II) repeat I for low-fidelity but higher-complexity tasks; and (III) repeat I and II in that order at subsequent levels of fidelity. The numbers of fidelity levels and complexity levels within fidelity levels needed depend on the aims of the course, curriculum or individual learning trajectory. This paper concludes with suggestions for future research based on this model.

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The overall purpose of the ‘Statistical Points and Pitfalls’ series is to help readers and researchers alike increase awareness of how to use statistics and why/how we fall into inappropriate choices or interpretations. We hope to help readers understand common misconceptions and give clear guidance on how to avoid common pitfalls by offering simple tips to improve your reporting of quantitative research findings. Each entry discusses a commonly encountered inappropriate practice and alternatives from a pragmatic perspective with no mathematics involved. We encourage readers to share comments on or suggestions for this section on Twitter, using the hashtag: #mededstats. The statement that a statistically significant outcome in a small sample must reflect a real effect is misleading and may result in overconfidence in findings obtained in small-sample studies. We recommend caution in drawing inferences for educational practice from small samples, and provide some practical tips for reporting at the end of this entry. We must remember that rejecting a null hypothesis is always accompanied with a chance that the null hypothesis was actually true. In a study, we take a sample to estimate results for the whole population from which the sample is taken. Means, correlation coefficients, and other sample findings tend to be imprecise estimates of the corresponding population parameters of interest when sample sizes are small [1]. As recognized by most researchers, small samples tend to have very limited statistical power for detecting population differences (e.g., between groups) and relations (i.e., between variables) of interest. That is, even if a rather substantial difference or relation exists in the population from which we sample, small samples often fail to obtain a statistically significant difference or relation. Consequently, using small samples, we will often fail to reject the null hypothesis of no difference or no relation when that null hypothesis is not true. This testing error is called a Type II error [1], familiar to most researchers. So when a small sample size produces a significant difference, researchers erroneously conclude, ignoring the possibility of Type II error, that the difference must reflect a real effect. However, researchers appear to be less aware of the fact that of all statistically significant findings obtained, a larger portion results in Type I errors (i.e., rejecting a null hypothesis that is true) in the case of small samples when compared with samples of a larger size. It is important to understand this issue, as it challenges the aforementioned misconception that a statistically significant outcome in a small sample must reflect a real effect. Let us, therefore, elaborate on this issue in a bit more detail.

Contains fulltext : 137158.pdf (Publisher’s version ) (Open Access) There is a growing need for research on culture, cultural differences and cultural effects of globalization in medical education, but these are complex phenomena to investigate. Socio-cultural activity theory seems a useful framework to study cultural complexity, because it matches current views on culture as a dynamic process situated in a social context, and has been valued in diverse fields for yielding rich understandings of complex issues and key factors involved. This paper explains how activity theory can be used in (cross-)cultural medical education research. We discuss activity theory's theoretical background and principles, and we show how these can be applied to the cultural research practice by discussing the steps involved in a cross-cultural study that we conducted, from formulating research questions to drawing conclusions. We describe how the activity system, the unit of analysis in activity theory, can serve as an organizing principle to grasp cultural complexity. We end with reflections on the theoretical and practical use of activity theory for cultural research and note that it is not a shortcut to capture cultural complexity: it is a challenge for researchers to determine the boundaries of their study and to analyze and interpret the dynamics of the activity system.

In this issue, Patel et al. [1] ask the question whether dissection is the only way to learn anatomy. The authors discuss some of the methods that students at a non-dissection based medical school have found beneficial to gain anatomical knowledge. In particular, they focus on the use of anatomy videos on YouTube, virtual models and the teaching of anatomy by surgeons in theatre. Exploring other options is not far-fetched when considering the space, time and money required to maintain a dissection room, and the problems many medical schools around the world encounter when trying to obtain enough cadavers. The paper by Patel et al. [1] is another contribution to the ongoing debate about cadaver dissection as an educational tool. I agree that cadaver dissection is indeed not the only way to teach and learn anatomy, but that does not mean we should disregard it. Review studies have compared dissection to the use of prosected specimens (in which students can study whole or parts of cadavers dissected by anatomy staff in advance) [2] and other teaching tools [3]. Although not straightforward, the results seem to be slightly in favour of dissection. However, research has also shown that a dissection course is not a uniform learning experience [4]. Different students have different approaches in dealing with dissection, therefore undergoing divergent learning experiences, which may result in differences in the amount and form of knowledge between individuals. As this possibly applies to all learning methods, it should not come as a surprise that a combination of methods to learn anatomy gives the best results. An example is the study by Biasutto et al. [5] who found better results for students who only dissected cadavers compared with students who only used computer resources, but reported the best scores for the group of students who learned by both dissection and the use of computer resources. In light of these results, I personally feel that we need to answer the when, what and how of anatomy education. When is the best moment to study anatomy in the dissection room? A recent study seems to indicate that anatomy education in the dissection room is most useful in the second of three steps of learning anatomy [6]. First, students can learn the vocabulary of anatomy (i.e. the names of the structures) through lectures or e-learning. Second, studying and understanding the 3D relationships of structures is best done in the dissection room, at least until 3D software and glasses become mainstream. The third step, discussing how anatomical knowledge can be used to explain signs and symptoms, can be done in settings such as tutorial groups. Furthermore, advocates of the use of dissection in undergraduate education frequently mention the (extra) opportunity for students to work on additional learning objectives, such as professionalism, manual dexterity, teamwork, self- and peer-evaluation, ethics etc. (e.g. Gregory et al. [7]). Norman [8] has suggested that most medical specialists who rarely get to see inside the body may well get by with studying simplified anatomy, e.g. with schematics in textbooks and plastic life-like models, and may even benefit from such an approach. This idea may contribute to the interesting fact that while cadaver dissection seems to be on the way out in undergraduate education, it is gaining popularity in postgraduate education. Next to acquiring specific in-depth anatomical knowledge on the region(s) of interest, the dissection room is widely used to practice technical skills such as surgical or anaesthesiological approaches, performing an endoscopy, laparoscopy, biopsy, ultrasound etc. (e.g. Kshettry et al. [9]). I think the future will show us that postgraduate education is an (additional) appropriate moment to study anatomy in the dissection room. What anatomical knowledge can be studied with which learning method? While less complex structures (e.g. abdominal organs) can be studied from a textbook or cadaver material, it is possible that students may get a better understanding of more complex anatomical structures (e.g. bones of the skull, the brain, course of a blood vessel) from virtual models. However, virtual models that have all the advantageous functions as described by Patel et al. [1] are not always instantly easy to navigate and need high-quality computers to run smoothly. In addition, the costs to obtain a license which makes a virtual model available to a large number of students can become very high. These issues may inhibit the full or partial substitution of cadaver dissection by virtual models in medical schools in certain countries. In contrast, YouTube is accessible without charge around the world. Although using videos may be a very popular learning method and certainly has a lot of benefits [1, 10], Azer [11] and Raikos and Waidyasekara [12] have shown that YouTube is currently an inadequate source of information for learning at least surface anatomy and heart anatomy. Both studies looked at more than 200 uploaded videos, and found that only around 25 % of them provided adequate anatomical content. With over 50,000 hits in the first search for heart anatomy videos, and the absence of videos covering surface anatomy of, among others, the head and neck region, some students might perceive using YouTube as challenging, time consuming and frustrating as other students perceive cadaver dissection to be. When considering YouTube as an alternative or additional learning method, it seems indispensable that the involved faculty guides students in the search and selection of the best resources. How should anatomical knowledge be taught? After decades of debate about cadaver dissection as a learning method, I feel we can conclude that there is no single method that can function as an answer for how anatomy should be taught. In my opinion it is not about the method you are using, but about how you are using it. Strategies such as increasing ‘time on task’, creating occasions for repetition and scaffolding (constructive learning), including opportunities for interaction between learners (collaborative learning) and placing learning in a context (contextual learning) are crucial when it comes to knowledge acquisition and retention [13]. The circumstances in which teaching methods are utilized are imperative, and fortunately these learning principles can be applied independently from any teaching method. Furthermore, the effect of a teaching method is often connected to the guidance students receive during their learning. Learning anatomy may benefit from ‘directed self-learning’ (in contrast to self-directed learning), suggesting self-study should be guided by experts in the subjects of both anatomy and medicine [14]. Because insufficient or excessive support can hamper a learning process, it is critical to determine the right type and amount of support (teaching methods) and guidance (presence and input of a teacher) and to fade at the appropriate time and rate [15]. It is true that in the past, lectures and cadaver dissection by students themselves was seen as essential to anatomy learning, and that anatomists and clinicians worry about the detrimental effect on students’ knowledge when removing the time-honoured method of cadaver dissection from anatomy education. However, complaints about declining anatomical knowledge were also heard before this process started [16]. Furthermore, students seem to be insecure about their anatomical knowledge, and keen to augment their knowledge using any learning method, regardless of the way they are taught [17, 18]. Although opinions may differ as to its scope, there is a general consensus that medical students definitely cannot do without anatomical knowledge, and consequently without anatomy education. However, in medical education today, the key question regarding anatomy education increasingly focuses on how education can be made as effective as possible. Therefore, it is important that future research investigates what and how students learn from dissection and other teaching methods, in order to provide teachers (and students) with information on which they can base their choices.

The overall purpose of the 'Statistical Points and Pitfalls' series is to help readers and researchers alike increase awareness of how to use statistics and why/how we fall into inappropriate choices or interpretations. We hope to help readers understand common misconceptions and give clear guidance on how to avoid common pitfalls by offering simple tips to improve your reporting of quantitative research findings. Each entry discusses a commonly encountered inappropriate practice and alternatives from a pragmatic perspective with no mathematics involved. We encourage readers to share comments on or suggestions for this section on Twitter, using the hashtag: #mededstats.

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I am writing this letter because I am worried about the increasing use of subjective data in the field of Health Professions Education, including publications in Perspectives on Medical Education. Let me first state that there is nothing wrong with the use of subjective data as such. It is clearly the best way to go for answering research questions dealing with opinions, perceptions and feelings. Asking people ‘what they think’, ‘how they see things’ and ‘how they feel’ then yields valuable data. But it is wrong to think that all research questions can be reliably answered on the basis of such subjective data. When we are interested in behaviour and cognitive processes, subjective data are often not reliable and may even be misleading. Let me give three reasons for this. First, participants are often inclined to ‘please the experimenter’. As soon as an experimenter sits in a room with his or her participants, gives them a task and watches them intently, they will start saying what they think the experimenter expects from them. The characteristics of the experimenter may also influence how participants will act during the experiment, a phenomenon known as ‘experimenter bias.’ This bias might even have a biological basis. For example, in one study participants were asked to rate their pain tolerance and pain unpleasantness [1]. When the experimenter was a high-status university professor they indicated higher pain tolerance and lower pain unpleasantness than when the experimenter was a low-status research assistant. Interestingly, blood pressure reactivity mediated the relation between experimenter status and pain tolerance, suggesting that the higher status of the experimenter elicits physiological adaptations that reduce sensitivity to pain. Second, researchers may easily forget that the relationship between attitudes and behaviour is weak [2]. When we ask people what they think about separating waste (separate disposal of paper, glass, plastic etc.), many of them will say they are in favour of it. And when we ask people what they think of wind energy, again many of them will say they are in favour of it. This is really their attitude, meaning that they are not ‘lying’ to the experimenter but giving their trustworthy opinion. Yet, we would be making a big mistake if we concluded that these people will indeed separate their waste or accept a wind turbine in their neighbourhood. Many of the people who are in favour of separating waste will not do so, simply because it is not part of their daily behavioural routines. And many of the people who are in favour of wind energy may protest when a wind turbine is planned in their own neighbourhood, something called the NIMBY syndrome (Not In My Back Yard). Third, many cognitive processes are largely unconscious or intuitive (also called type 1 processes; [3]), and when we ask people to reflect on these processes they will often ‘construct’ plausible answers. Again, they really believe in their answers but nevertheless they are not in line with their actual behaviour. In a recent study, for example, we asked experienced radiologists how they visually studied X-rays in order to reach a diagnosis [4]. Most of them said they used ‘systematic viewing’, ensuring that all parts of the image are carefully inspected in a systematic fashion and thus yielding full coverage of the image. This is also the way they teach visual diagnosis to their students. Interestingly, eye-tracking data showed that this is not what expert radiologists actually do; compared with students, they use more systematic viewing but show less coverage because they ignore irrelevant parts of the image. However, this is a highly automated process they are simply not aware of. My message is rather straightforward. Subjective data are valuable but when researchers are interested in measuring behaviour or cognitive processes it is always best to combine them with more objective data. Too often, what people say is not what people do!

Many readers of this journal are involved in teaching or designing educational programmes or studies. Often, either by yourself or in conjunction with others, you need to design studies asking questions such as what is the best approach for teaching this material for a particular type of learner? What context makes a difference in learner performance? What strategies motivate learners better than others? In planning these studies, there are many design considerations necessary to ensure that the results are meaningful. During the planning of the studies, and subsequently, numerous questions arise concerning the use of statistics. We recognize that medical educational researchers are often not particularly comfortable with statistics and thus could easily slip into making poor decisions about what to do with quantitative data in the study. Even if your study is designed carefully, choices made inherently lead to a study that has both strengths and limitations. You are now faced with the question of how to present the outcomes of your study and how to formulate implications for educational practice and future research. In this process, you have a diverse toolbox at your disposal from which you need to select tools to match your study, the research questions, and the nature of the data collected. In some types of studies, we tend to make inappropriate data choices [1] either because we are not aware of better alternatives or of how much difference these alternatives can make for the interpretations of findings and the implications thereof for educational practice and future research. A new section of Perspectives on Medical Education, entitled Statistical points and pitfalls, directly tackles these analytical issues. The overall purpose of this series is to help readers and researchers alike increase awareness of how to use statistics, why and how we fall into inappropriate choices or interpretations, and what we can do about it. We hope to help readers understand common misconceptions and give clear guidance on how to avoid common pitfalls by offering simple tips to improve the reporting of quantitative research findings. Each entry discusses a commonly encountered inappropriate practice and offers alternatives from a pragmatic perspective with no mathematics involved. This issue’s inaugural edition of Statistical points and pitfalls addresses the question of when it is appropriate to do a statistical test. In it, we present the conditions that ought to be met for a statistical test to be used and what to do otherwise [2]. Whether you are an educator trying to select the most appropriate methods to deliver effective learning for your students, a researcher trying to improve your reporting of quantitative findings, or simply want to gain a critical understanding of the literature that you read, this section is for you. If you supervise others’ research but you struggle to give concrete feedback on how to improve, you will also find useful assistance here. Suggestions for future editions of this section can be shared on Twitter, using the hashtag #mededstats. We hope you find Statistical points and pitfalls accessible, instructive, and entertaining.

The question ‘what is good clinical teaching?’ has intrigued medical education researchers for decades. We have tried to determine the characteristics of good clinical teachers, and have sought ever better ways to train and evaluate them. These research efforts have brought forward a myriad of publications that have resulted in faculty development programmes, quality improvement efforts and even frameworks for promotion and tenure. Clinical teaching and all efforts to improve it are strongly influenced by the fact that they are situated within a workplace context in which patient-centred care is increasingly dependent on the collaboration of interprofessional health care teams. Add time pressure and budgetary constraints to the mix and one gets a perfect storm which we like to call the clinical learning environment. It is in this environment that medical students are socialized into their chosen profession. Teaching and supervision are essential to the learning process of students in the clinical workplace because students need feedback and support to help structure their learning experiences and reflect on their competence development. What strikes me, however, is that our efforts to improve clinical teaching consistently focus on individual clinical teachers. Some results from more recent research indicate that it would perhaps be more naturalistic to approach clinical teaching as a team effort and not primarily as a solo endeavour [1, 2]. And moreover, some findings suggest that it could be worthwhile to move beyond our focus on physicians as the only teachers of medical students, and to embrace the teaching potential of other health care professionals who operate in the clinical learning environment [3, 4]. Looking beyond the one-on-one relationship between a student and a teacher and widening our scope to the level of team or community of practice, there is a larger movement visible within the medical education domain. Alan Bleakley, in his 2006 paper on ‘broadening conceptions of learning in medical education: the message from teamworking’, advocated a stronger focus on socio-cultural models of learning over ‘individualistic learning models’ to ‘explain how learning occurs in dynamic, complex and unstable systems such as fluid clinical teams’ [5]. So let us further explore the clinical teaching team concept: how could we define it and what would its potential research implications be? Patient care is a team effort. As students (be they medical students or residents) learn by participating in this team effort, they are exposed to various (allied) health care professionals. Where some of these professionals might be more focused on the students’ clinical reasoning and medical knowledge, other professionals will focus on the students’ communication and collaboration skills. For example, the role of nurses in facilitating students’ understanding of workflow and ‘how things work around here’ seems to be common knowledge and even taken for granted. But what does this facilitation actually entail? The focus on the individual physician as the clinical teacher creates a blind spot with regard to the potential of the interprofessional health care team at large to function as ‘teacher’, and thus to the distributed nature and multiplicity of teaching within the workplace. The team perspective highlights the notion that all these health care professionals potentially have something to offer and can complement one another’s individual competencies to train medical students and residents. The communities of clinical practice (CoCP) perspective offers a potential theoretical research avenue for exploring the clinical teaching team concept [6]. CoCP opens up the boundaries of the original communities of practice concept to move from a mono-professional entity to a multi-professional entity. The unifying element in both concepts is the activities of the community in pursuit of a shared enterprise. In a health care setting this shared enterprise can be defined as patient care. Understanding the interplay and dynamic within the community of clinical practice might help create a richer picture of the clinical learning environment and the potential ‘teachers’ within this environment. From a more pragmatic point of view one could use the CanMEDS roles, or any other competency framework, as a lens to understand how residents learn to communicate and collaborate interprofessionally, and to examine the role that allied health professionals play in this process. Or how the community of clinical practice interplay teaches residents to become leaders or more effective health advocates? Although the role of allied health care professionals in the learning process of students is readily recognized, professional boundaries and hierarchy within the clinical workplace will have likely created a barrier to explore the potential of the clinical teaching team. The physician has long been seen as ‘the one’: the one who is solely responsible for teaching medical students to become medical doctors. I feel that it might be worthwhile to try and look beyond professionals boundaries and include the allied health professionals in our understanding of who might fulfill the role of clinical teachers. Looking beyond the power of ‘the one’ might just help medical students to navigate their perfect storm.

Transitions in medical education are challenging for students, postgraduate trainees, their preceptors, and everyone else in the workplace [1]. This issue of Perspectives on Medical Education features a paper by Atherley and colleagues that clearly illustrates these challenges for undergraduate medical students [2]. They focused their transition study on the shift of context that students experience within rotation-based clerkships when moving from one rotation to the next. Some interesting findings emerged. For instance, students recognized the need to start a new rotation with a positive attitude and to try and develop a good relationship with staff. Paradoxically, both intentions could require students to ignore reputations of a rotation and its people. If not ignored, anticipation could stand in the way of taking full advantage of the learning opportunities of a rotation [2]. Fortunately, many students reported that the struggle of working through a transition added to their professional identity development and led to increased confidence. Besides contributing to our insight into transitions, Atherley and colleagues’ paper significantly contributes to medical education research in another way. It is a great example of theory-informed medical education research. The researchers chose organizational socialization theory as their framework to study student transitions. In their introduction they described the components provided by this theory: newcomer characteristics, behaviours, and organizational efforts, their influences on newcomer adjustments and ultimately the outcomes of the process of organizational socialization [3]. This conceptual framework was not forced upon the data. It was used dialectically to both inform data analysis and lead to theory refinement. In their discussion, Atherley and colleagues based their implications and recommendations on an adapted version of the organizational socialization model that they started with [2]. Theory-informed research in medical education can take many shapes, from the example referred to above to quantitative research where theory informs hypothesis testing or qualitative research where theory determines how phenomena should be interpreted [4, 5]. Theory provides researchers with ‘ways of thinking about a problem or a study, or ways of representing how complex things work the way they do’ [6]. More broadly speaking, it offers a framework of concepts to apply to the research problem under investigation. Bordage explained that conceptual frameworks originate from [6]: theories with well-organized principles and propositions that have been confirmed by observations or experiments; models derived from theories, observations or sets of concepts, or evidence-based best practices derived from outcome and effectiveness studies. Although having a conceptual framework to guide your studies may seem a very welcome tool to medical education researchers, many struggled to use it in their work. For over 15 years, worries about the lack of explicitly mentioned conceptual frameworks in medical education research have been published in leading journals. In 2000, Prideaux and Spencer commented: ‘the advancement of medical education also requires that it draws on a strong theoretical base from the parent discipline of education’ [7]. In a critical examination of experimental studies in medical education published in 2003–2004, Cook and colleagues found that only 55 % presented a conceptual framework [8]. In 2010, two commentaries again had to conclude that there was still a lack of research that clearly describes how it was informed by and built on a conceptual framework [9, 10]. Now, in 2016, I believe it is fair to say that the field of medical education research seems to have taken this criticism seriously. The number of conceptual frameworks that could be relevant to medical education researchers appears to be increasing. Journals have dedicated special sections to papers that introduce concepts from fields such as psychology, sociology, anthropology, architecture, or neurosciences. However, for individual researchers and the teams in which they work, engaging with conceptual frameworks will require continuous efforts. In my own experience and in working with (PhD) researchers and giving workshops on the topic, I found that recognizing there are many potentially relevant concepts surrounding one’s topic of research is both necessary and confusing. There is a parallel between medical students transitioning to a new rotation and medical education researchers engaging with (new) conceptual frameworks. Although you know there is much to learn from engaging with new ideas and concepts, it is also impossible to know at the start how you will manage to achieve a positive outcome while the possibility of ‘getting lost’ is looming. In order to constructively engage with conceptual frameworks and to help others to do the same, I find it helpful to recognize the contributions of the preconditions: freedom and safety. Any researcher, certainly one who enters a new field of study, will have to find the personal and social freedom to challenge assumptions. Understanding why a research question is of interest to you or your team is usually not that difficult to answer. However, scientific research requires adding a piece of knowledge or insight to issues that transcend local problems that may have led to the research. One’s context should not be viewed as the reason for a study but as the practice in which a study can be conducted [11]. The research question should be grounded in one of the theories, models or previous studies that also form the origins of conceptual frameworks. This shift of perspective offers freedom to individual researchers and their teams to explore and subsequently choose from the multiple lines of reasoning that could underpin a research question. The freedom that comes with making these choices can lead to uncertainty: can I become familiar enough with unknown theories, models or previous research in order conduct this research, do I want to make the shift away from local problems as the reason for study? For these and other questions to be answered confirmatory, researchers need to feel safe. Safe enough to ask these questions and know that other team members will help explore new conceptual frameworks or help open up access to insightful sources of information or subject experts. Safe enough to make the shift away from local problems to using one’s context to add a little piece of knowledge to science. In the end, it is this process that will eventually help find more sophisticated answers to local problems. Just as in a transition, it takes trust in your struggle to achieve personal, and in this case scientific, development.

As Jan van Dalen opened in a previous issue [1], ‘It is every Editor’s dream that articles in “their” journal serve a wide population of interested readers.’ But how do we succeed in producing such articles? What is of crucial importance is that an article provides answers to the questions ‘What is new?’ and ‘What is in there for me?’, and that it does not comprise too many elements that distract from these core answers. Cognitive load theory [2] provides a framework for how to do exactly that. In cognitive load theory, learning is the gradual development and refinement of schemata (i.e., existing knowledge) in long-term memory, and processing new information—information that is not yet part of these schemata—requires working memory load or cognitive load [3]. The extent to which an article presents new information depends on the level of expertise of the individual reader. For example, experts who have studied the human brain for quite some years tend to have very elaborate schemata of the human brain or at least of particular regions of the brain. Novice students, who have barely read or seen anything about the human brain, on the contrary, have virtually no schemata about the human brain or particular brain regions at all. If we wish to serve our entire reading audience, we need to take care that there is something new in our articles for both groups but that we do not overload the novice readers. Explaining core assumptions and choices in sufficient detail is one way of managing this so-called intrinsic cognitive load [4] on the reader’s mind, providing references where readers can find more details and fill gaps in their knowledge is another way. If we fail to explain core assumptions and choices, or fail to provide accessible references on core issues about which we feel we cannot expand too much in our article (for instance, due to wording limits), we may overload potentially interested but novice readers, and we may lose their interest. Meanwhile, if we fail to provide meaningful answers to the questions ‘What is new?’ and ‘What is in there for us?’ we are unlikely to see experts in the field read our article, let alone use it for future research. Apart from this so-called intrinsic cognitive load, which is defined by the amount of new information in the article (i.e., information that is not yet part of readers’ schemata), we may impose some extraneous cognitive load [5] on readers’ minds due to the way in which we present the information to our readers. For instance, suppose that—in a certain situation—a simple graph provides a clear explanation of particular findings. If we use lots of equations and jargon instead of such a graph, we require readers to process information that—in this particular situation—is not necessary for understanding the findings. Likewise, if we use large quantities of text to describe something like blood flow in the human body when a simple diagram can explain the same process equally well, having to process all that text seems extraneous to learning about the core process. An attractive and clear presentation of various parts of an article can help to minimize this redundant cognitive load and stimulate readers to deal with the intrinsic cognitive load (i.e., ‘What is new?’ and ‘What is in there for me?’). In short, a good article has an interesting message that imposes some intrinsic cognitive load but as little as possible extraneous cognitive load on the reader’s mind. Something tells me that the articles in this issue have been accepted for publication exactly because they meet this criterion.

Blended learning in which online education is combined with face-to-face education is especially useful for (future) health care professionals who need to keep up-to-date. Blended learning can make learning more efficient, for instance by removing barriers of time and distance. In the past distance-based learning activities have often been associated with traditional delivery-based methods, individual learning and limited contact. The central question in this paper is: can blended learning be active and collaborative? Three cases of blended, active and collaborative learning are presented. In case 1 a virtual classroom is used to realize online problem-based learning (PBL). In case 2 PBL cases are presented in Second Life, a 3D immersive virtual world. In case 3 discussion forums, blogs and wikis were used. In all cases face-to-face meetings were also organized. Evaluation results of the three cases clearly show that active, collaborative learning at a distance is possible. Blended learning enables the use of novel instructional methods and student-centred education. The three cases employ different educational methods, thus illustrating diverse possibilities and a variety of learning activities in blended learning. Interaction and communication rules, the role of the teacher, careful selection of collaboration tools and technical preparation should be considered when designing and implementing blended learning.

Studies in medical education can serve a variety of purposes. Studies that have a predominantly quantitative orientation may focus on estimating relations between variables, on estimating effects of one or more variables on some other variable(s), or on series of causal relations or mechanisms. Which is the focus of a particular study depends on the theoretical framework and research questions of that study. However, theory is of fundamental importance to medical education research, and studies focusing on series of causal relations or mechanisms can contribute greatly to the advancement of medical education research. This paper presents the potential benefits which result from adopting a path analysis perspective on the estimation of causal relations and conceptualization of mechanisms in medical education research.

As the new Editor in Chief, I will use this editorial to give a brief outline of my vision for the future of the journal. As the english-language successor to the dutch-language journal of the Dutch Association for Medical Education (NVMO), ‘Perspectives on Medical Education’ has become a fully-fledged international scientific journal. I commend the editorial board on this achievement. It provides me, together with the editorial board, with an excellent starting point for further growth. We opt to position the journal on the cutting edge of educational research and development, offering quality papers that are of interest to teachers, educational developers, policy makers and researchers: a position between more theory-oriented journals, such as Advances in Health Sciences Education and Medical Education on one hand and on the other hand journals with a more practical focus, such as clinical teacher. We invite authors to submit papers that focus on the transition of theory to practice and if possible on the impact on patient care. Clinicians are an important target group for Perspectives. In the coming period we will communicate this course through the editorials, commentaries, some new rubrics and manuscript categories. Firstly, we will update and globalize the Practical Guidelines to Clinical Education that were developed for the dutch-language version of the journal. Two associate editors—Bob McKinley and Fedde Scheele—will invite international experts to update the existing guidelines for practice on topics such as multi-source feedback, entrustable professional activities, and the interpretation of assessment data. Second, a new section for papers in which experienced experts give a state of the art overview of their field has been added. The first author to contribute to this section is one of our new editors—Cees van der Vleuten. In one of the coming issues he will give his perspective on how evidence can be translated to medical education. Third, we would like to focus the journal more broadly than medicine and also give space to the other health professions. We will make this more explicit in the definition of the aim of the journal and in the membership of the editorial board. In line with this is our plan for a section for papers on inter-professional education. Finally, we will start a section with papers that give a policy perspective to medical education. We will appoint associate editors with expertise in these domains. In my opinion, it is essential that Perspectives achieves an impact factor, as this is likely to entice significantly more researchers to opt for Perspectives as the platform for their publications. Important requirements for eligibility for an impact factor are: papers which are cited by other researchers in the field, reliable and timely publication of the journal, short lead time of submitting an article to decision and possible publication, and an international team of editors. We will focus our attention on good quality papers and a timely response to authors. For good quality papers, constructive feedback from editors and reviewers to the authors is essential. To achieve this, the review process has been reorganized. The Editor in Chief reads and makes an initial assessment of all incoming papers. At this stage, unsuitable papers are rejected and others are sent for assessment to one of the associate editors—who are committed to the journal and have a network of potential reviewers. The associate editor rejects or sends the paper for review to a reviewer who is knowledgeable on the topic in question. These first two screenings by the Editor in Chief and associate editor will promote economical use of reviewer time without concessions as regards the quality of the review process.