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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 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 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.)

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.

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.

Purpose: Values and value systems are fundamental to medical school admissions processes. An axiological analysis was carried out to explore the individual values and value systems found within the University of Calgary's Cumming School of Medicine's undergraduate admissions process., Method: A mixed-methods case study methodology was developed with a focus on applicant characteristics viewed as desirable, the relative value ascribed to applicant characteristics, the values that participants in admissions processes brought to bear, the values that were reflected in the artifacts and procedures used in support of admissions processes, and the values that were expressed at a system, program, or institutional level. The study employed a descriptive audit of admissions processes, a stakeholder survey, stakeholder interviews, and a discourse analysis of admissions materials (all carried out between June and September 2017)., Results: The study found that, despite a general sense of satisfaction with the rigor of the admissions process, there was less satisfaction with the final selection it produced. Participants wanted to see more attention paid to responsibilities to patients and society than to gender and ethnic balance., Conclusions: Those involved with medical school admissions need to be mindful of their value systems and use them to align intent with process and outcomes in selecting tomorrow's physicians. Axiological analysis of medical education processes can play a central role in reviewing and refocusing efforts on meeting an institution's social mission and medical education's social contract.

Purpose: There has been scant scholarly attention paid to characterizing how the numerous definitions of terms associated with compassion and humanism have been mobilized or what the organizational implications of pursuing different constructs might be. This study explored the uses and implications of the terminology associated with humanistic medicine in the work of the Associated Medical Services (AMS) Phoenix Project., Method: This study involved two phases (2014-2015). First, two pilot group workshops with AMS Phoenix Project participants and stakeholders were conducted to explore ways of parsing and interpreting core concepts used in the project. The authors then assembled an archive of texts associated with the project, comprising the project website and blog posts, conference proceedings, and fellowship and grant applications. Informed by critical discourse analysis, the authors identified, described, and analyzed core terms related to the project's mission and explored the type of health care practices and reforms implied by their use., Results: Two recurring core terms, care/caring and compassion, and eight clusters of terms related to these core terms were identified in the archive. Caring and compassion as terms were articulated in various psychological, sociological, and political configurations. This polysemy reflected a diverse array of health care reform agendas., Conclusions: Understanding how different interpretations of caring and compassion cluster around core topics and concerns of humanistic medicine offers scholars an entry point for comparing and appraising the quality and direction of reform agendas, including multilevel strategies that involve systems-level changes.

The collection and analysis of data are central to medical education and medical education scholarship. Although the technical ability to collect more data, and medical education's dependence on data, have never been greater, it is getting harder for medical schools and educational scholars to collect and use data, particularly in terms of the regulations, security issues, and growing reluctance of learners and others to participate in data collection activities. These two countervailing trends present a growing threat to the viability of medical education scholarship. In response, there must either be a more conducive data environment for medical education scholarship or medical education must move to become less dependent on data.There is, therefore, a growing need for a system-wide correction: a shift in practice that makes data use more viable and productive while maintaining high professional standards. There are five core areas that can contribute to a system-wide correction: greater clarity over what can be used as data; greater clarity on what constitutes "good" data; changes to the ways in which data are collected; better strategic stewardship of existing data; and deliberate and strategic attention to "data readiness" in support of medical education and medical education scholarship. These solutions are primarily practical and conceptual changes in the face of what are mainly regulatory challenges. However, medical educators also need to engage with emerging areas of practice such as learning analytics, and they need to consider the shifting social contract for using data in medical education.

Purpose: Triple C is the Canadian competency-based medical education (CBME) initiative for family medicine. The authors report on a study exploring the impacts Triple C has had across Canada., Method: A multi-institutional team conducted a realist study to explore the impact of Triple C implementation in different programs across Canada. Data were collected between March and June 2016 from interviews and focus groups with key medical school stakeholders. Data were analyzed using thematic and template analysis techniques., Results: Data were acquired from 16 of the 17 Canadian medical schools from a combination of program leaders, educators, and trainees. Triple C was implemented in different ways and to different extents depending on context. Newer sites tended to have a more comprehensive implementation than established sites. Urban sites afforded different opportunities to implement Triple C from those afforded by rural sites. Although it was too early to assess its impact on the quality of graduating residents, Triple C was seen as having had a positive impact on identifying and remediating failing learners and on energizing and legitimizing the educational mission in family medicine. Negative impacts included greater costs and tensions in the relationships with other specialties. A principles-based approach to CBME offered flexibility to programs to incorporate variation in their interpretation and implementation of Triple C. Although there was a degree of normalization of practice, it was not standardized across sites or programs., Conclusions: Triple C has been successfully implemented across Canada but in differing ways and with different impacts.

Changes in the health care landscape over the last 25 years have led to an expansion of training sites beyond the traditional academic health sciences center. The resulting contextual diversity in contemporary medical education affords new opportunities to consider the influence of contextual variation on learning. The authors describe how different contextual patterns in clinical learning environments-patients, clinical and educational practices, physical geography, health care systems, and culture-form a contextual learning matrix. Learners' participation in this contextual matrix shapes what and how they learn, and who they might become as physicians.Although competent performance is critically dependent on context, this dependence may not be actively considered or shaped by medical educators. Moreover, learners' inability to recognize the educational affordances of different contexts may mean that they miss critical learning opportunities, which in turn may affect patient care, particularly in the unavoidable times of transition that characterize a professional career. Learners therefore need support in recognizing the variability of learning opportunities afforded by different training contexts. The authors set out the concept of the contextual curriculum in medical education as that which is learned both intentionally and unintentionally from the settings in which learning takes place. Further, the authors consider strategies for medical educators through which the contextual curriculum can be made apparent and tangible to learners as they navigate a professional trajectory where their environments are not fixed but fluid and where change is a constant.

There has been a widespread shift to competency-based medical education (CBME) in the United States and Canada. Much of the CBME discourse has focused on the successful learner, with relatively little attention paid to what happens in CBME systems when learners stumble or fail. Emerging issues, such as the well-documented problem of "failure to fail" and concerns about litigious learners, have highlighted a need for well-defined and integrated frameworks to support and guide strategic approaches to the remediation of struggling medical learners.This Perspective sets out a conceptual review of current practices and an argument for a holistic approach to remediation in the context of their parent medical education systems. The authors propose parameters for integrating remediation into CBME and describe a model based on five zones of practice along with the rules of engagement associated with each zone. The zones are "normal" curriculum, corrective action, remediation, probation, and exclusion.The authors argue that, by linking and integrating theory and practice in remediation with CBME, a more integrated systems-level response to differing degrees of learner difficulty and failure can be developed. The proposed model demonstrates how educational practice in different zones is based on different rules, roles, responsibilities, and thresholds for moving between zones. A model such as this can help medical educators and medical education leaders take a more integrated approach to learners' failures as well as their successes by being more explicit about the rules of engagement that apply in different circumstances across the competency continuum.