Search

Although feedback is often presented as if it were a well-understood concept in health professions education, in practice it can mean many things. For some, feedback is a conversation about defining and improving performance, while for others it is the information generated by assessments and tools. Indeed, feedback has variously been defined as a process, as data, as a conversation, and as a reflective exercise. As a result, for a concept so central to what educators do, 'feedback' is ambiguous and has multiple meanings. Pattern theory affords opportunities to examine what scholars and practitioners mean when they use the term 'feedback'. Elaborating feedback as a pattern system can connect otherwise disjointed discourses of feedback. In this paper, the authors describe the development of a pattern system of feedback in medical education. Arksey & O'Malley's 5-stages of scoping reviews were adapted to enact a 6-step pattern system development methodology that included (1) Identifying the research question and scope of inquiry; (2) elaborating a strategy for pattern identification; (3) study selection; (4) abductive pattern representation development; (5) pattern system testing; and (6) summarizing and reporting the results. A pattern system of feedback was developed based on review of 218 full text articles and testing against an additional 2833 citations. This pattern system is made up of 36 pattern representations organized under 6 domains: feedback referent, feedback intentions, feedback information, feedback processing, feedback response, and feedback meta. The pattern system was applied to two models of feedback to demonstrate its utility as a lens through which to analyze various instances of feedback and to foreshadow its potential broader applicability as a tool to facilitate knowledge synthesis in the feedback problem space., (© 2024. The Author(s).)

Introduction: Discourse analysis has been used as an approach to conducting research in health professions education (HPE) for many years. However, because there is no one 'right' interpretation of or approach to it, quite what discourse analysis is, how it could or should be used, and how it can be appraised are unclear. This ambiguity risks undermining the trustworthiness and coherence of the methodology and any findings it produces., Method: A meta-study review was conducted to explore the current state of discourse analysis in HPE, to guide researchers engaging using the methodology and to improving methodological, analytical and reporting rigour. Structured searches were conducted, returns were filtered for inclusion and 124 articles critically analysed., Results: Of 124 included articles, 64 were from medical education, 51 from nursing and 9 were mutli-disciplinary or from other HPE disciplines. Of 119 articles reporting some sort of data, 50 used documents/written text as the sole data source, while 27 were solely based on interview data. Foucault was the most commonly cited theorist (n = 47), particularly in medical education articles. The quality of articles varied: many did not provide a clear articulation what was meant by discourse, definitions and methodological choices were often misaligned, there was a lack of detail regarding data collection and analysis, and positionality statements and critiques were often underdeveloped or absent., Discussion: Seeking to address these many lacunae, the authors present a framework to facilitate rigorous discourse analysis research and transparent, complete and accurate reporting of the same, to help readers assess the trustworthiness of the findings from discourse analysis in HPE. Scholars are encouraged to reflect more deeply on the applications and practices of discourse analysis, with the ultimate aim of ensuring more breadth and depth when using discourse analysis for understanding and constructing meaning in our field., (© 2024 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Abstract: What constitutes evidence, what value evidence has, and how the needs of knowledge producers and those who consume this knowledge might be better aligned are questions that continue to challenge the health sciences. In health professions education (HPE), debates on these questions have ebbed and flowed with little sense of resolution or progress. In this article, the authors explore whether there is a problem with evidence in HPE using thought experiments anchored in Argyris' learning loops framework.From a single-loop perspective ("How are we doing?"), there may be many problems with evidence in HPE, but little is known about how research evidence is being used in practice and policy. A double-loop perspective ("Could we do better?") suggests expectations of knowledge producers and knowledge consumers might be too high, which suggests more system-wide approaches to evidence-informed practice in HPE are needed. A triple-loop perspective ("Are we asking the right questions?") highlights misalignments between the dynamics of research and decision-making, such that scholarly inquiry may be better approached as a way of advancing broader conversations, rather than contributing to specific decision-making processes.The authors ask knowledge producers and consumers to be more attentive to the translation from knowledge to evidence. They also argue for more systematic tracking and audit of how research knowledge is used as evidence. Given that research does not always have to serve practical purposes or address the problems of a particular program or institution, the relationship between knowledge and evidence should be understood in terms of changing conversations and influencing decisions., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

The concept of professional resistance describes the principles professionals should follow when they seek to counter social harm and injustice. Applied to medical education, the principles of professional resistance can help learners and teachers balance the responsibilities to respond to harm and injustice with their roles and responsibilities as health professionals. However, there remains the problem of how educators and leaders can constructively respond to learner acts of resistance. It would seem that many leaders have dismissed learner resistance with variations on "Those Darn Kids!", a complaint that has long been levied at those in younger generations who challenge power and authority. How can productive change in medical education be achieved if learners' complaints are not taken seriously? Rather than dismissal, leaders and educators in these situations need the tools to engage learners in conversations that draw out their concerns.

Phenomenon: Learners in medical education are often exposed to content and situations that might be experienced as traumatic, which in turn has both professional and personal implications. The purpose of this study was to synthesize the literature on how trauma has been conceptualized and approached within medical education, and the implications thereof., Approach: A metanarrative approach was adopted following the RAMESES guidelines. Searches of 7 databases conducted in January 2022 with no date limitations yielded 7,280 articles, of which 50 were identified for inclusion through purposive and theoretical sampling. An additional 5 articles were added from manual searches of reference lists. Iterative readings, interpretive and reflexive analysis, and research team discussions were performed to identify and refine metanarratives., Findings: Five metanarratives were identified, including the concept of trauma, the trauma event, the person with trauma, the impact of trauma, and addressing trauma, with each metanarrative encompassing multiple dimensions. A biomedical concept of trauma predominated, with lack of conceptual clarity. Theory was not integrated or developed in the majority of articles reviewed, and context was often ambiguous. Trauma was described in myriad ways among studies. Why certain events were experienced as trauma and the context in which they took place were not well characterized. The impact of trauma was largely concentrated on harmful effects, and manifestations beyond symptoms of post-traumatic stress were often not considered. Furthermore, the dominant focus was on the individual, yet often in a circumscribed way that did not seek to understand the individual experience. In addressing trauma, recommendations were often generic, and earlier research emphasized individually-focused interventions while more recent studies have considered systemic issues., Insights: Multiple dimensions of trauma have been discussed in the medical education literature and from many conceptual standpoints, with biomedical, epidemiologic, and individualized perspectives predominating. Greater precision and clarity in defining and understanding trauma is needed to advance research and theory around trauma in medical education and the associated implications for practice. Exploring trauma from intersectional and collective experiences and impacts of trauma and adapting responses to individual needs offers ways to deepen our understanding of how to better support learners impacted by trauma.

Background: Despite the constant presence of change and innovation in health professions education (HPE), there has been relatively little theoretical modelling of such change, the experiences of change, the ideology associated with change or the unexpected consequences of change. In this paper, the authors explore theoretical approaches to the adoption of innovations in HPE as a way of mapping a broader theoretical landscape of change., Method: The authors, HPE researchers with an interest in technology adoption and systemic change, present a narrative review of the literature based on a series of thought experiments regarding how communities and individuals respond to the introduction of new ideas or methods. This research investigates the stages of innovation adoption, from the emergence and hype around new ideas to the concrete experiences of early adopters., Results: When an innovation first emerges, there is often little concrete information available to inform potential adopters, leaving it susceptible to hype, both positive and negative. This can be described using the Gartner Hype Cycle model, albeit with important caveats. Once the adoption of an innovation gets underway, early adopter user experiences can inform those that follow. This can be described using Rogers' diffusion of innovation model, again with caveats. Notably, neither model goes beyond the point of single point-in-time, yes/no, individual adoption. Other approaches, such as learning curve theory, are needed to track uptake and maintenance by individuals over time., Significance: This expanded theoretical base, while still somewhat instrumentalist, combined with complementary theoretical perspectives can afford opportunities to better explore reasons for variance, volunteerism and resistance to change. In summary, change is complicated and nuanced, and better models and theories are needed to understand and work meaningfully with change in HPE. To that end, the authors seek to encourage richer and more thoughtful research and scholarly thinking about change and a more nuanced approach to the pursuit of change in HPE as a whole., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: The growing interest in knowledge translation and implementation science, both in clinical practice and in health professions education (HPE), is reflected in the number of studies that have sought to address what are believed to be evidence-practice gaps. Though this effort may be intended to ensure practice improvements are better aligned with research evidence, there is a common assumption that the problems researchers explore and the answers they generate are meaningful and applicable to practitioner needs., Methods: This Mythology paper considers the nature of problems from HPE as the focus of HPE research and the ways in which they may or may not be aligned. The authors argue that, in an applied field such as HPE, it is vital that researchers better understand how their research problems relate to practitioner needs and what the limitations on evidence uptake might be. Not only can this establish clearer paths between evidence and action, but it also requires a rethink of much of knowledge translation and implementation science thinking and practice., Results: The authors explore five myths: whether everything in HPE is a problem; whether practitioner needs involve problem solving; whether practitioner problems are resolvable with sufficient evidence; whether researchers effectively target practitioner problems; and whether studies that focus on solving practitioner problems make significant contributions to the literature., Conclusions: To advance the conversation on the connections between problems and HPE research, the authors propose ways in which knowledge translation and implementation science might be approached differently., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Documents, from policies and procedures to curriculum maps and examination papers, structure the everyday experiences of health professions education (HPE), and as such can provide a wealth of empirical information. Document analysis (DA) is an umbrella term for a range of systematic research procedures that use documents as data., Methods: A meta-study review was conducted with the aims of describing the current state of DA in HPE, guiding researchers engaging in DA and improving methodological, analytical and reporting rigour. Structured searches were conducted, returns were filtered for inclusion and the 115 remaining articles were critically analysed for their use of DA methods and methodologies., Results: There was a significant increase in the number of articles reporting the use of DA over time. Sixty-three articles were single method (DA only), while the others were mixed methods research (MMR). Overall, there were major lacunae in terms of why documents were used, how documents were identified, what the authors did and what they found from the documents. This was particularly apparent in MMR where DA reporting was typically poorer than the reporting of other methods in the same paper., Discussion: Given these many lacunae, a framework for reporting on DA research was developed to facilitate rigorous DA research and transparent, complete and accurate reporting of the same, to help readers assess the trustworthiness of the findings from document use and analysis in HPE and, potentially, other domains. It was also noted that there are gaps in HPE knowledge that could be addressed through DA, particularly where documents are conceptualised as more than passive holders of information. Scholars are encouraged to reflect more deeply on the applications and practices of DA, with the ultimate aim of ensuring more substantive and more rigorous use of documents for understanding and constructing meaning in our field., (© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Throughout history, physicians have been involved in acts of resistance to systems of harm and injustice. However, resistance has seemed to have had little legitimate place in physician professionalism or in formal professional practice. As the challenges to physicians and the profession continue to mount, there is a pressing need to understand how it might be articulated and understood. To do that we need to consider past instances of physician resistance to injustice and harm. A scoping review was conducted to understand how often and in what contexts physicians have been engaged in resistance. A search of multiple bibliographic databases returned 2123 papers, which, after filtering for relevance and inclusion, left 60 articles for full-text review. Of these, 95% were from the United States, suggesting that issues of legitimacy are even more acute outside the U.S. Narrative findings were organized around four themes: professional responsibility to resist, legitimate resistance, resistance to perceived threats, and resistance as moral agency. When physicians have resisted, they have done so with a sense of moral agency albeit with different levels of altruism. They have often engaged in resistance when they felt their personal and professional interests are threatened, with particular emphasis on threats to physician autonomy. The study suggests that, within the U.S. at least, physician resistance is a matter for concern but, it has been approached with little or no guidance or grounding. Moreover, there is a longstanding tension between those who have argued that physicians have a professional responsibility to resist and those who have considered resistance to be extraneous and even harmful to their work as healers. At a time when physicians are facing an ever-growing number of practical, ethical, and moral challenges, professional acts of resistance are of critical concern within the profession., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Background: There is little evidence to show what scope of practice (SOP) means from the point of view of family physicians, how family physicians think about their SOP as it changes over time, or what factors shape and influence their SOP. Understanding family physician perspectives on SOP and the factors that influence it can aid our understanding of how it can constrain and enable physicians' agency and autonomy in professional practice., Methods: Using qualitative description and incorporating constructivist grounded theory data collection and analysis techniques, four focus groups were conducted involving twenty-four Ontario-based family physicians from different contexts, at different career stages, and with different practice experiences., Results: Participants' SOP was highly dynamic, changing throughout their careers due to factors both within and beyond their control. Their sense of their own SOP was the product of a continuous cycle of personal and professional transitions, exposures, and experiences throughout their careers. These family physicians sought regular and sustained mentorship, support, and engagement for their SOP throughout their careers. This was particularly the case during professional transitions and for drivers of their SOP for which they felt unprepared early in their careers, such as through the first years of independent practice, and when functioning as owner-operators of medical practices. Four descriptive themes were identified focusing on the nature of their current practice, their professional preparedness and supports, practice management dynamics, and 'doctors are people, too'., Conclusions: The SOP of the family physicians in this study was dynamic and unique to each individual, it emerged from interactions between their personal and professional lives and identities, and it was embedded in their lived experiences. SOP was also to some extent imposed and externally driven. This study advances understanding by exploring the 'why' and 'how' of SOP rather than focusing solely on what it is., (© 2022. The Author(s).)

Objective: To report on contextual variance in the distributed rural family medicine residency programs of 3 Canadian medical schools., Design: A constructivist grounded theory methodology was employed., Setting: Rural and remote postgraduate family medicine programs at the University of Alberta, the University of British Columbia, and the University of Calgary., Participants: Twenty-six family practice residents were interviewed, providing descriptions of 27 different rural sites and 10 regional sites., Methods: Interviews were audiorecorded, transcribed verbatim, and thematically analyzed., Main Findings: Participants differentiated between main campus academic health science centres; regional referral hub sites; and smaller, rural, and more remote community sites. Participants described major differences between sites in terms of patient, practice, educational, physical, institutional, and social factors. The differences between training sites included variations in learning opportunities; physical challenges related to weather, distance, and travel; and the social opportunities offered. There were also differences in how residents perceived their training sites, both in terms of what they noticed and how they interpreted their observations and experiences. Although there were contextual differences between regional sites, those differences were a lot less than between different smaller rural and remote sites. These differences shaped the learning opportunities available to residents and influenced their well-being., Conclusion: Although there may be some similarities between distributed training sites, each training context presents unique challenges and opportunities for the family medicine residents placed there. More attention to the specific affordances of different training contexts is required., (Copyright © 2022 the College of Family Physicians of Canada.)

Introduction: The lack of attention to transgender and gender diverse (TGD) people in undergraduate medical education (UME) is a point of concern, particularly among medical students. A project was undertaken to develop a UME curriculum framework for teaching the healthcare needs of TGD people., Methods: Using a modified Delphi methodology, four rounds of surveys were presented to an expert stakeholder group that included content experts, generalist physicians, UME teaching faculty, and medical students. Questions covered what content should be taught, who should teach the content, and how much time should be dedicated for this teaching. Once the Delphi process was complete, feedback on the provisional framework was sought from members of the TGD community to ensure it represented their needs and perspectives., Results: 71 panel members and 56 community members participated in the study. Core values included the scope of the framework, and topics such as inclusivity, and safety in practice and in teaching. The framework included terminology, epidemiology, medical and surgical treatment, mental health, sexual and reproductive health, and routine primary care. There was also guidance on who should teach, time to be allocated, and the learning environment., Discussion: There is a clear need to train tomorrow's doctors to provide competent and respectful healthcare services to and for TGD patients. Although local factors will likely shape the way in which this framework will be implemented in different contexts, this paper outlines a core UME-level curriculum framework for Canada and, potentially, for use in other parts of the world., (© 2021. The Author(s).)

Implementation science approaches the challenges of translating evidence into practice as a matter of scientific inquiry. This conceptual paper uses an implementation science lens to examine the ways in which evidence from health professions education research is brought to bear on decision-making. The authors describe different decision-making contexts and the kinds of evidence they consider, and from this, they outline ways in which research findings might be better presented to support their translation into policy and practice. Reflecting on the nature of decision-making in health professions education and how decisions are made and then implemented in different health professions education contexts, the authors argue that researchers should align their work with the decision-making contexts that are most likely to make use of them. These recommendations reflect implementation science principles of packaging and disseminating evidence in ways that are meaningful for key stakeholders, that stem from co-creation of knowledge, that require or result in meaningful partnerships, and that are context specific and relevant., (© 2021. The Author(s).)

The role that resistance plays in medicine and medical education is ill-defined. Although physicians and students have been involved in protests related to the COVID-19 pandemic, structural racism, police brutality, and gender inequity, resistance has not been prominent in medical education's discourses, and medical education has not supported students' role and responsibility in developing professional approaches to resistance. While learners should not pick and choose what aspects of medical education they engage with, neither should their moral agency and integrity be compromised. To that end, the authors argue for professional resistance to become a part of medical education. This article sets out a rationale for a more explicit and critical recognition of the role of resistance in medical education by exploring its conceptual basis, its place both in training and practice, and the ways in which medical education might more actively embrace and situate resistance as a core aspect of professional practice. The authors suggest different strategies that medical educators can employ to embrace resistance in medical education and propose a set of principles for resistance in medicine and medical education. Embracing resistance as part of medical education requires a shift in attention away from training physicians solely to replicate and sustain existing systems and practices and toward developing their ability and responsibility to resist situations, structures, and acts that are oppressive, harmful, or unjust.

The conceptualisation of 'good' medical education research as hypothesis testing to identify universal truths that are generalisable across contexts has been challenged. Joining this conversation, the field of health professions education research is complex and contextual and there are ways of examining and reporting locally based activities and innovations, which can be of general value. This position leads to a focus on case study research (CSR), inquiry bound in time and place that generates thick descriptions and close interpretations to reach explanations. CSR has grown in sophistication in recent years and can inform practice and advance the science of medical and health professions education. The authors evaluated the current state of the science of CSR in the medical education literature by identifying and reviewing 160 papers. Most articles presented as 'case studies' were not in fact CSR. Moreover, most articles failed to go beyond a 'we did this' account. The authors explore definitions of CSR, and they examine dominant CSR methodologists, Yin, Stake and Merriam, and their respective approaches to CSR. They then set out some of the basic tenets of CSR (case definition, methods of data collection and analysis) and consider the logics of CSR (its structures, purposes, assumptions and symbols). CSR challenges are considered next (such as emic and etic perspectives; ethical complexities; generalisability; quality; and reporting and reflexivity). The authors conclude that context is a mechanism, which needs to be understood, and rigorous CSR provides the structures and criticality to do so, opening up new areas of understanding and inquiry., (© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

The transition to the assessment of entrustable professional activities as part of competency-based medical education (CBME) has substantially increased the number of assessments completed on each trainee. Many CBME programs are having difficulty synthesizing the increased amount of assessment data. Learning analytics are a way of addressing this by systematically drawing inferences from large datasets to support trainee learning, faculty development, and program evaluation. Early work in this field has tended to emphasize the significant potential of analytics in medical education. However, concerns have been raised regarding data security, data ownership, validity, and other issues that could transform these dreams into nightmares. In this paper, the authors explore these contrasting perspectives by alternately describing utopian and dystopian futures for learning analytics within CBME. Seeing learning analytics as an important way to maximize the value of CBME assessment data for organizational development, they argue that their implementation should continue within the guidance of an ethical framework., (Copyright © 2021 by the Association of American Medical Colleges.)

This paper introduces a new column in the Journal for the exploration of and reflection on the roles and articulations of theory in the health professions education sciences. This introduction provides initial orientation to concepts such as theory as worldview, theory linked to empiricism and paradigm, and theory and reflexivity. The authors invite scholars to submit papers that explore the role of theory in HPE scholarship, that propose new and adapted theoretical positions, and that critique the many theories that might be brought to bear to address questions in the field.

Introduction: Knowledge syntheses in medical education are intended to promote the translation to, and mobilization of, research knowledge into practice. Despite the effort invested in conducting them, how these knowledge syntheses are used is unclear. This study aimed to explore how knowledge syntheses published by the Best Evidence Medical Education Collaboration (BEME) have been used in a cross-section of published literature., Methods: Citation patterns for BEME reviews were explored using data drawn from Web of Science and Scopus, and a sub-sample of citing papers., Results: Bibliometric data on 3419 papers citing 29 BEME reviews were analysed. More detailed data were extracted from a random sample of 629 full-text papers., Discussion: BEME reviews were most often positioned to consolidate and summarize the current state of knowledge on a particular topic and to identify gaps in the literature; they were also used to justify current research, and less frequently to contextualize and explain results, or direct future areas of research. Their use to identify instruments or methodological approaches was relatively absent., Conclusion: While BEME reviews are primarily used to justify and support other studies, the current literature does not demonstrate their translation to educational practice.

Phenomenon: Social studying and learning (SSL) is any independent, elective, self-directed and self-organized approach to learning that involves students working with their peers for the purposes of study, learning, or revision. While in-class collaborative learning has been relatively well-explored, very little is known about how medical students engage in informal SSL or about the impacts it can have. The purpose of this study was to explore medical students' practices and perceptions regarding SSL, and the ways in which this shaped their overall learning experiences. Approach: A constructivist grounded theory study was conducted at the University of Calgary. Data were collected from 23 semi-structured student interviews, which were audio recorded and transcribed. Data were analyzed using iterative data collection, memo-ing, and focused coding. Findings: Despite SSL being a common part of students' medical school experience and something that was promoted by academic advisors, how students actually engaged with SSL varied substantially, including who made use of SSL, how they made use of it, the size and focus of SSL groups, how these groups functioned, and what individuals sought to get out of them. Some students found SSL helped them to be more efficient and focused in their studying, while others benefited from comparing their knowledge and skills with those of their peers. Not everyone benefited, as some students found SSL stressful, unproductive, or socially uncomfortable. While student engagement in SSL was an enabler of academic success for some it could also be an indicator of social isolation and low self-esteem for others. Insights : Understanding how SSL can influence student experiences has the potential to inform students how and why they might engage in SSL, and it can help educators better support their students, particularly in those schools that actively encourage SSL.

The philosophy of science is concerned with what science is, its conceptual framing and underlying logic, and its ability to generate meaningful and useful knowledge. To that end, concepts such as ontology (what exists and in what way), epistemology (the knowledge we use or generate), and axiology (the value of things) are important if somewhat neglected topics in health professions education scholarship. In an attempt to address this gap, Academic Medicine has published a series of Invited Commentaries on topics in the philosophy of science germane to health professions educational science. This Invited Commentary concludes the Philosophy of Science series by providing a summary of the key concepts that were elucidated over the course of the series, highlighting the intent of the series and the principles of ontology, epistemology, axiology, and methodology. The authors conclude the series with a discussion of the benefits and challenges of cross-paradigmatic research.

Understanding complex interventions, such as in medical education, requires a philosophy of science that can explain how and why things work, or fail to work, in different contexts. Critical realism and its operationalization in the form of realist inquiry provides this explanatory power. Ontologically, critical realism posits that the social world is real, that it exists independent of our knowledge of it, and that it is driven by causal mechanisms. However, unlike postpositivism, a realist epistemological position is that our understanding of the mechanisms that underlay social reality is limited and subjective. Critical realism is focused on understanding the mechanisms that drive social reality even when they are not directly observable. One of the most commonly used methodologies in the critical realist paradigm is realist inquiry, which focuses on the relationships between context, mechanisms, and outcomes. At its core, realist inquiry is concerned with "What works for whom, under what circumstances, how, and why?" To that end, realist inquiry explores the mechanisms that drive social systems and the ways in which these mechanisms work to develop explanatory theories of the phenomena under consideration. Although, compared with other approaches, realist inquiry is relatively new in medical education, the value of realist inquiry is in its ability to model how complex interventions function differently across multiple contexts, explaining what works, how it works, for whom, and in what contexts.

In this commentary, we highlight some of the pressing choices and sacrifices we must make in medical education during the COVID-19 pandemic.

Postmodernism emerged in the mid-20th century in the context of postwar Europe where philosophers and artists were taking increasingly skeptical and critical positions on modernist thinking and practice. Postmodernism is not a single organized and coherent perspective; it is a collection of related philosophies, techniques, models, and perspectives that take a skeptical and critical perspective on thinking and practice. Ontologically, postmodernism is predicated on the belief that power and its underlying meanings, manipulations, and ideologies shape our ability to act in and think about the world. Epistemologically, postmodernism seeks to explore and understand underlying meanings, structures, and intents in the world and to consider alternative explanations and interpretations for them. Axiologically, postmodernism can be used to analyze value in the context of inequity, oppression, and hegemony within social systems and structures. Due to the lack of coherence within postmodernist thought, there is no one definitive methodological stance. However, there are many postmodernism-informed methodological stances, which vary both in terms of what is examined and how it is examined. As an approach within medical education, postmodernist perspectives can help to expose and analyze the political and ideological positioning of much of what is done, particularly in the interests of addressing systemic problems of justice and equity. It is somewhat paradoxical that postmodernism allows researchers to challenge the nature and expression of truth, and it allows them to problematize and deconstruct the ideologies and agendas of those who are themselves challenging the nature and expression of truth.

Background: Compassion is intrinsically situated within particular contexts and how these contexts can shape compassion has not been well-described., Objective: The purpose of the study was to describe how individual and contextual challenges can impact compassion within critical care and palliative care settings., Design: This qualitative study adopted phenomenology and autoethnography to inform data collection, and principles of activity theory and realist inquiry for data interpretation., Participants: Five clinicians who work in critical care (n = 3) and palliative care (n = 3) participated in the study., Approach: Qualitative data were obtained from ethnographic observations, interviews, and focus groups. Participants observed and recorded field notes (n = 53) on instances of suffering and compassion in their workplace settings. At the end of the study period, they participated in a focus group or individual interview to reflect on their experiences. Data was analyzed using constructivist grounded theory techniques and iteratively synthesized through group discussion and model building., Key Results: The findings reflected four phenomena associated with compassion in context: individual gaps and lapses in compassion, relational challenges, contextual constraints on compassion, and distributed compassion. Individual gaps and lapses in compassion involved inattention, intention vs. perception, personal capacity, and personal toll. Relational challenges included receptivity, fragmentation, and lack of shared understanding. Contextual constraints consisted of situational pressures, the clinical environment, gaps in education, and organizational culture. The distribution of compassion within teams and how teams adapt their behaviors in response to perceived needs for greater compassion modulated these challenges., Conclusions: The study illustrates the many ways in which compassion can be shaped by context and highlights the role of teamwork in identifying gaps and lapses in compassion and responding in a way that supports patients, families, and colleagues.