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Andrés Martin,1– 3 Marco A de Carvalho Filho,3,4 Debbie Jaarsma,3,5 Robbert Duvivier3,6 1Child Study Center, Yale School of Medicine, New Haven, CT, USA; 2Simulated Participant Program, Teaching and Learning Center, Yale School of Medicine, New Haven, CT, USA; 3Center for Educational Development and Research in Health Sciences (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, Groningen, the Netherlands; 4School of Medical Sciences, University of Minho, Braga, Portugal; 5Faculty of Veterinary Medicine, University of Utrecht, Utrecht, the Netherlands; 6Parnassia Psychiatric Institute, The Hague, the NetherlandsCorrespondence: Andrés MartinYale Child Study Center, 230 South Frontage Road, New Haven, CT, 06520-7900, USATel +1 203-494-2355Fax + 1 203-785-7400Email andres.martin@yale.eduObjective: Innovations in contemporary medical education could inform remedies to address enduring challenges such as the marginalization and stigmatization of psychiatry, of mental illnesses, and of those affected by them.Methods: In blending the works of Bleakley, Bligh, and Brown (2011) and of Kumagai and Naidu (2015), we developed an overarching heuristic with practical relevance and concrete applications to psychiatric education.Results: We identify three areas to enhance psychiatric education embedded into this blended framework: 1) Showing, or the more accurate depiction or imaging of mental illnesses and of psychiatric practice, as exemplified by the incorporation into didactic content of asynchronous video-based clinical materials produced with specific educational objectives in mind; 2) Sharing, or addressing the image problem of mental illnesses, of those living with or affected by them, and of psychiatry as a profession, as exemplified by psychiatrists embracing their role as experts by professional and personal experience when sharing their own journeys with mental illness, treatment, and recovery; and 3) Doing, or reimagining reflective psychiatric practice, as exemplified by the novel methodology of co-constructive patient simulation (CCPS), through which learners can engage in reflective practice and supervision in a participatory and democratic setting that does not privilege participants’ hierarchical standing.Conclusion: The blended model and the sample applications we describe offer a range of teaching, learning, and professional development opportunities, should psychiatric educators choose to pursue them and reap their promise.Keywords: medical education, psychiatry, reflective practice, simulated patients, stigma, video-enhanced didactic

Abstract Background The role of deliberate practice in medical students' development from novice to expert was examined for preclinical skill training. Methods Students in years 1-3 completed 34 Likert type items, adapted from a questionnaire about the use of deliberate practice in cognitive learning. Exploratory factor analysis and reliability analysis were used to validate the questionnaire. Analysis of variance examined differences between years and regression analysis the relationship between deliberate practice and skill test results. Results 875 students participated (90%). Factor analysis yielded four factors: planning, concentration/dedication, repetition/revision, study style/self reflection. Student scores on 'Planning' increased over time, score on sub-scale 'repetition/revision' decreased. Student results on the clinical skill test correlated positively with scores on subscales 'planning' and 'concentration/dedication' in years 1 and 3, and with scores on subscale 'repetition/revision' in year 1. Conclusions The positive effects on test results suggest that the role of deliberate practice in medical education merits further study. The cross-sectional design is a limitation, the large representative sample a strength of the study. The vanishing effect of repetition/revision may be attributable to inadequate feedback. Deliberate practice advocates sustained practice to address weaknesses, identified by (self-)assessment and stimulated by feedback. Further studies should use a longitudinal prospective design and extend the scope to expertise development during residency and beyond.

Background: Evidence indicates that communication skills teaching learnt in the classroom are not often readily transferable to the assessment methods that are applied nor to the clinical environment. An observational study was conducted to objectively evaluate students' communication skills in different learning environments. The study sought to investigate the extent to which the communication skills demonstrated by students in classroom, clinical, and assessment settings align., Method: A mixed methods study was conducted to observe and evaluate students during the fourth year of a five-year medical program. Participants were videorecorded during structured classroom 'interactional skills' sessions, as well as clinical encounters with real patients and an OSCE station calling upon communication skills. The Calgary Cambridge Observational Guides was used to evaluate students at different settings., Result: This study observed 28 students and findings revealed that while in the classroom students were able to practise a broad range of communication skills, in contrast in the clinical environment, information-gathering and relationship-building with patients became the focus of their encounters with patients. In the OSCEs, limited time and high-pressure scenarios caused the students to rush to complete the task which focussed solely on information-gathering and/or explanation, diminishing opportunity for rapport-building with the patient., Conclusion: These findings indicate a poor alignment that can develop between the skills practiced across learning environments. Further research is needed to investigate the development and application of students' skills over the long term to understand supports for and barriers to effective teaching and learning of communication skills in different learning environments., (© 2024. The Author(s).)

Background: Recent years, there has been increasing attention to disciplinary law, both in (mental) healthcare and in society. Specific quantitative data are limitedly available., Aim: Gaining insight into disciplinary jurisprudence, particularly the number/type of complaints, concerning psychiatrists and medical residents working in psychiatry., Method: Descriptive retrospective study. All published decisions of regional disciplinary tribunals from the period 2020-2023 concerning psychiatrists and psychiatric medical residents were examined., Results: During the research period, regional disciplinary tribunals handled 190 unique disciplinary complaints; an average of 47.5 per year. 176 complaints concerned a psychiatrist and 14 complaints a medical resident. Most complaints were about ‘incorrect treatment/wrong diagnosis’, ‘other complaints’, or ‘incorrect statement or report’. 15.3% resulted in a sanction, mainly warnings., Conclusion: Over the past four years, there have been fewer disciplinary complaints annually against psychiatrists and psychiatric medical assistants compared to the five years before that. The nature of the complaints has remained largely unchanged, but fewer complaints resulted in a sanction. This exploratory analysis suggests the need for periodic follow-up research.

Background: Education in electroconvulsive therapy (ECT) has become mandatory in the Dutch psychiatry training. ECT is still relatively rarely used. To increase knowledge about ECT, we have developed a training module about ECT for psychiatrist training. To promote flexible learning, we opted for e-learning, where educational principles have been applied in the design., Aim: In this article we discuss how this e-learning ECT was developed and analyze the learning outcomes for psychiatry residents., Method: The e-learning has been developed based on the ADDIE model and consists of an entrance test, various assignments and a final test. The learning outcomes of the first 216 residents have been analyzed quantitatively and qualitatively using test results, self-assessments of their expertise in ECT (before and after) and evaluations., Results: Of the participating residents, 94% found this education relevant to practice. The e-learning was rated with an average of 8.3. Afterwards, one’s own knowledge about ECT was estimated to be significantly higher than before. Afterwards, 72% thought they can indicate ECT more quickly and 99% reported that they can better inform patients and families about ECT., Conclusion: The e-learning ECT is appreciated by residents and leads to an experienced improvement in knowledge about ECT.

Background: Patient simulation has been used in medical education to provide a safe and supportive learning environment for learners to practice clinical and interpersonal skills. However, simulation involving pediatric populations, particularly in child and adolescent psychiatry, is rare and generally does not reflect the child-caregiver dyad or the longitudinal aspects of this care, nor does it provide learners with an opportunity to engage with and reflect on these dynamics., Methods: We organized as an educational opportunity a series of seven observed patient simulation sessions with a cohort of a dozen child and adolescent psychiatrists (eight fellows approaching graduation and four senior educators). In these sessions, we utilized the co-constructive patient simulation model to create the simulation cases. We included the use of at least two patient actors in most sessions, and two of the case narratives were longitudinally followed across multiple simulation sessions. We approached the data collected during the simulations and their respective debriefings by using thematic analysis informed by a symbolic interactionist approach., Results: Based on data from the debriefing sessions and longitudinal narratives, we identified four overarching themes: (1) Reflecting on dyadic challenges: role reversal and individuation; (2) Centering the child, allying with the parent, and treating the family system; (3) Ambivalence in and about the parent-child dyad; and (4) Longitudinal narratives and ambivalence over time., Conclusion: The emotional experience of the simulations, for interviewers and observers alike, provided an opportunity to reflect on personal and professional experiences and triggered meaningful insights and connections between participants. These simulated cases called for emotional labor, particularly in the form of creating holding environments; in this way, the simulated encounters and the debriefing sessions became dialogic experiences, in which the patient and provider, parent and child, and learner and instructor could co-construct meaning and foster professional development as reflective practitioners., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Introduction: Despite various efforts to develop communication skills (CS) in the classroom, the transfer of these skills into clinical practice is not guaranteed. This study aimed to identify barriers and facilitators of transferring CS from the classroom to clinical environments., Methods: A qualitative study was conducted at one Australian medical school to explore the experiences and perceptions of facilitators and students in relation to teaching and learning clinical CS. Thematic analysis was used to analyze data., Results: Twelve facilitators and sixteen medical students participated in semi-structured interviews and focus-group discussions, respectively. Primary themes included the value of teaching and learning, alignment between approaches to teaching and actual clinical practices and students' perceptions of practice, and challenges in different learning environments., Discussion: This study reinforces the value of teaching and learning CS by facilitators and students. Classroom learning provides students with a structure to use in communicating with real patients, which can be modified to suit various situations. Students have limited opportunities, however, to be observed and receive feedback on their real-patient encounters. Classroom session that discussed CS experiences during clinical rotation is recommended to strengthen learning both the content and process of CS as well as transitioning to the clinical environment., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Dewi, Wilson, Duvivier, Kelly and Gilligan.)

Background: In The Netherlands, physicians specialized in global health and tropical medicine (Ps-GHTM) are trained to work in low-resource settings (LRS) after their training program of 27 months. After working for a period of time in LRS, many Ps-GHTM continue their careers in the Dutch healthcare system. While there is limited evidence regarding the value of international health experience for medical students and residents, it is unknown to what extent this applies to Ps-GHTM and to their clinical practice in the Netherlands., Methods: In this qualitative study we conducted semi-structured interviews and focus group discussions (FGDs) with Ps-GHTM to explore the perceived applicability of their experience abroad for their subsequent return to the Netherlands. Topic guides were developed using literature about the applicability of working abroad. Findings from the interviews served as a starting point for FGDs. The interviews and FGDs were analysed using directed content analysis., Results: 15 themes are described relating experience abroad to healthcare delivery in The Netherlands: broad medical perspective, holistic perspective, adaptive communication skills, creativity, flexibility, cultural awareness, self-reliance, clinical competence, cost awareness, public health, leadership, open-mindedness, organization of care, self-development, and teamwork. Highlighting the variety in competencies and the complexity of the topic, not all themes were recognized by all respondents in the FGDs nor deemed equally relevant. Flexibility, cultural awareness and holistic perspective are examples of important benefits to work experience in LRS., Conclusion: Ps-GHTM bring their competencies to LRS and return to the Netherlands with additionally developed skills and knowledge. These may contribute to healthcare delivery in the Netherlands. This reciprocal value is an important factor for the sustainable development of global health. Identifying the competencies derived from work experience in LRS could give stakeholders insight into the added value of Ps-GHTM and partly help in refining the specialization program., (© 2023. The Author(s).)

Objective: Repeated practice, or spacing, can improve various types of skill acquisition. Similarly, virtual reality (VR) simulators have demonstrated their effectiveness in fostering surgical skill acquisition and provide a promising, realistic environment for spaced training. To explore how spacing impacts VR simulator-based acquisition of surgical psychomotor skills, we performed a systematic literature review., Methods: We systematically searched the databases PubMed, PsycINFO, Psychology and Behavioral Sciences Collection, ERIC and CINAHL for studies investigating the influence of spacing on the effectiveness of VR simulator training focused on psychomotor skill acquisition in healthcare professionals. We assessed the quality of all included studies using the Medical Education Research Study Quality Instrument (MERSQI) and the risk of bias using the Cochrane Collaboration's risk of bias assessment tool. We extracted and aggregated qualitative data regarding spacing interval, psychomotor task performance and several other performance metrics., Results: The searches yielded 1662 unique publications. After screening the titles and abstracts, 53 publications were retained for full text screening and 7 met the inclusion criteria. Spaced training resulted in better performance scores and faster skill acquisition when compared to control groups with a single day (massed) training session. Spacing across consecutive days seemed more effective than shorter or longer spacing intervals. However, the included studies were too heterogeneous in terms of spacing interval, obtained performance metrics and psychomotor skills analysed to allow for a meta-analysis to substantiate our outcomes., Conclusion: Spacing in VR simulator-based surgical training improved skill acquisition when compared to massed training. The overall number and quality of available studies were only moderate, limiting the validity and generalizability of our findings., (© 2023. The Author(s).)

Interprofessional education (IPE) often uses collaborative learning for better teamwork among multiple professions. Its theoretical background is social interdependence theory (SIT), and positive interdependence is key for successful collaborative learning. As there is little theoretical knowledge on how to optimize the social interdependence in IPE, educators often struggle to develop an effective program. Therefore, a more specific explanation of the relationship between social interdependence and interprofessional readiness might make IPE more effective. We aimed to elucidate how students' social interdependence in collaborative learning relates to interprofessional readiness. Health profession students (n = 259) undertaking a collaborative IPE program were asked to complete two validated questionnaires: Readiness for Interprofessional Learning Scale and Social Interdependence Scale in Collaborative Learning. A structural equation analysis provided a good fit for the data. Awareness of objectives positively predicted interprofessional collaboration and identity, whereas specific roles as health professionals negatively predicted interprofessional roles and identity. As the current healthcare system is highly specialized, there is a dilemma that the more specific a problem is, the clearer it is which profession is responsible for solving it. Hence, strengthening awareness collaboratively may overcome the dilemma. Also, it is necessary to reconstruct a curriculum based on the premise of interprofessional activities.

Background: This paper describes the development of learning from novice to expert in Stage 4: Clinical Decision Making (CDM) in surgery: Postoperative reflection and review. It also outlines some or the assessment and teaching approaches suitable to facilitate that transition in skill level., Methods: This paper is drawn from a much broader study of learning and teaching CDM, that used qualitative methodology based on Constructivist and Grounded Theory. Data was collected in individual interviews and focus groups. Using thematic analysis the data were analysed to identify key ideas. All participants worked in the Department of Surgery at one large regional hospital in Victoria., Results: For each stage there is a sequence of learning beginning from relying on external resources, gradually developing internal resources to guide and direct the learner's CDM. Those internal resources built through experience include multisensory and kinaesthetic memories that expand to facilitate the ability to cope with complexity., Discussion: Armed with the mind-map and rubric table included in this paper it should be possible for any senior clinician or teacher to diagnose their trainees' progression in Stage 4 CDM. This will enable them to tailor their teaching to best match the capabilities of the trainee and to enable to be more effectively targeted., Conclusion: CDM can be taught and both trainees and senior clinicians can benefit from understanding the processes involved., (© 2022 Royal Australasian College of Surgeons.)

Background: Collaborative learning is a group learning approach in which positive social interdependence within a group is key to better learning performance and future attitudes toward team practice. Recent attempts to replace a face-to-face environment with an online one have been developed using information communication technology. However, this raises the concern that online collaborative learning (OCL) may reduce positive social interdependence. Therefore, this study aimed to compare the degree of social interdependence in OCL with face-to-face environments and clarify aspects that affect social interdependence in OCL., Methods: We conducted a crossover study comparing online and face-to-face collaborative learning environments in a clinical reasoning class using team-based learning for medical students (n = 124) in 2021. The participants were randomly assigned to two cohorts: Cohort A began in an online environment, while Cohort B began in a face-to-face environment. At the study's midpoint, the two cohorts exchanged the environments as a washout. The participants completed surveys using the social interdependence in collaborative learning scale (SOCS) to measure their perceived positive social interdependence before and after the class. Changes in the mean SOCS scores were compared using paired t-tests. Qualitative data related to the characteristics of the online environment were obtained from the focus groups and coded using thematic analysis., Results: The matched-pair tests of SOCS showed significant progression between pre- and post-program scores in the online and face-to-face groups. There were no significant differences in overall SOCS scores between the two groups. Sub-analysis by subcategory showed significant improvement in boundary (discontinuities among individuals) and means interdependence (resources, roles, and tasks) in both groups, but outcome interdependence (goals and rewards) improved significantly only in the online group. Qualitative analysis revealed four major themes affecting social interdependence in OCL: communication, task-sharing process, perception of other groups, and working facilities., Conclusions: There is a difference in the communication styles of students in face-to-face and online environments, and these various influences equalize the social interdependence in a face-to-face and online environment., (© 2022. The Author(s).)

BACKGROUND: Knowledge gaps and stigmatized perceptions regarding electroconvulsive therapy (ECT) among patients and health providers contribute to the underutilization of an important therapeutic modality. The proactive education of future advanced practice registered nurses (APRNs) provides an opportunity to optimize the use of this evidence-based clinical practice. AIMS: As part of a general course in psychiatry during the first year of nursing school, we dedicated 1 hour to treatment-refractory depression, including ECT, and a second hour to a summary discussion of mood disorders. We evaluated the efficacy of this didactic offering, which was co-taught by a psychiatrist and a psychiatric APRN. METHOD: At baseline, consenting students ( n = 94) provided three words they associated with ECT and then completed three validated instruments: (a) Questionnaire on Attitudes and Knowledge of ECT, (b) Opening Minds Stigma Scale for Health Care Providers, and (c) Self-Stigma of Seeking Help. Among the 67 students who repeated the assessment at endpoint, 39 attended the ECT didactic (Intervention group, 58%) and 28 did not (Control, 42%). RESULTS: After completion of the 3-month course, students showed improvement across all measures ( p < .001). The only outcomes that improved differentially between the Intervention and Control groups were the Questionnaire on Attitudes and Knowledge of ECT Attitudes and Knowledge scales ( p = .01). Word choice valence associated with ECT shifted favorably by endpoint ( p < .001). CONCLUSIONS: An educational intervention co-led by a psychiatric-mental health APRN had a significant impact on nursing students' knowledge and perceptions of ECT. This approach can be readily implemented at other institutions. Future refinements will include the videotaped depiction of a simulated patient undergoing the consent, treatment, and recovery phases of ECT.

Background: Many residents experience their transitions, such as from medical student to resident, as demanding and stressful. The challenges they face are twofold: coping with changes in tasks or responsibilities and performing (new) social roles. This process of 'learning the ropes' is known as Organizational Socialization (OS). Although there is substantial literature on transitions from the perspective of residents, the voices of program directors (PDs) who facilitate and guide residents through the organizational socialization process have not yet been explored. PDs' perspectives are important, since PDs are formally responsible for Postgraduate Medical Education (PGME) and contribute, directly or indirectly, to residents' socialization process. Using the lens of OS, we explored what strategies PDs use to facilitate organizational socialization of newcomer residents., Methods: We conducted semi-structured interviews with 17 PDs of different specialties. We used a theory-informing inductive data analysis study design, comprising an inductive thematic analysis, a deductive interpretation of the results through the lens of OS and, subsequently, an inductive analysis to identify overarching insights., Results: We identified six strategies PDs used to facilitate organizational socialization of newcomer residents and uncovered two overarching insights. First, PDs varied in the extent to which they planned their guidance. Some PDs planned socialization as an explicit learning objective and assigned residents' tasks and responsibilities accordingly, making it an intended program outcome. However, socialization was also facilitated by social interactions in the workplace, making it an unintended program outcome. Second, PDs varied in the extent to which they adapted their strategies to the newcomer residents. Some PDs used individualized strategies tailored to individual residents' needs and skills, particularly in cases of poor performance, by broaching and discussing the issue or adjusting tasks and responsibilities. However, PDs also used workplace strategies requiring residents to adjust to the workplace without much intervention, which was often viewed as an implicit expectation., Conclusions: PDs' used both intentional and unintentional strategies to facilitate socialization in residents, which may imply that socialization can occur irrespective of the PD's strategy. PDs' strategies varied from an individual-centered to a workplace-centered approach to socialization. Further research is needed to gain a deeper understanding of residents' perceptions of PD's efforts to facilitate their socialization process during transitions., (© 2022. The Author(s).)

Free amino acid (FAA) profiles of fresh, acidified, naturally fermented, and starter culture fermented cucumbers were analyzed by liquid chromatography triple quadrupole mass spectrometry. Fermented cucumbers contained more total FAA than acidified cucumbers (1,302 ± 102 mg/kg and 635 ± 35 mg/kg, respectively). Total FAA content of fermented cucumber was similar regardless of brine salt levels (2-6% NaCl) and starter culture addition. Glutamine (1491.4 ± 69.3 mg/kg), γ-aminobutyric acid (GABA, 269.6 ± 21.4 mg/kg), asparagine (113.0 ± 6.4 mg/kg), and citrulline (110.3 ± 8.5 mg/kg) were the most abundant FAA in fresh pickling cucumber, whereas GABA (181.3 ± 21.5 mg/kg), isoleucine (165.2 ± 11.2 mg/kg), leucine (129.8 ± 10.9 mg/kg), and lysine (110.9 ± 5.0 mg/kg) were the most abundant in fermented cucumber. GABA and ornithine were produced during fermentation, indicating glutamate decarboxylase and arginine deiminase activities. Notably, ornithine was significantly higher in natural (63.3 ± 31.5 mg/kg) versus starter culture fermented cucumbers (3.0 ± 0.7 mg/kg). This new information on FAA composition of fresh and fermented pickling cucumbers shows the impact of fermentation conditions on cucumber amino acid profiles while providing insight for manipulating fermentations for health promotion and consumer acceptance. PRACTICAL APPLICATION: This study reports changes in the free amino acid profiles of raw, fermented and acidified cucumbers, which may be valuable for understanding the impact of these foods on human health and nutrition. This information is useful for food microbiologists studying the metabolism of lactic acid bacteria during fermentation and/or designing starter cultures and could contribute to the development of novel fermented cucumber pickle products with enhanced nutritional value., (© 2022 Institute of Food Technologists. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Introduction: In simulation sessions using standardized patients (SPs), it is the instructors, rather than the learners, who traditionally identify learning goals. We describe co-constructive patient simulation (CCPS), an experiential method in which learners address self-identified goals., Methods: In CCPS, a designated learner creates a case script based on a challenging clinical encounter. The script is then shared with an actor who is experienced working as an SP in medical settings. An instructor with experience in the model is involved in creating, editing, and practicing role play of the case. After co-creation of the case, learners with no prior knowledge of the case (peers or a supervisor) interview the SP. The clinical encounter is followed by a group debriefing session., Results: We conducted 6 CCPS sessions with senior trainees in child and adolescent psychiatry. Topics that are difficult to openly talk about may be especially appropriate for the CCPS model-without overt guidance or solicitation, the scripts developed by learners for this series involved: medical errors and error disclosure; racial tensions, including overt racism; interprofessional conflict; transphobia; patient-on-provider violence; sexual health; and the sharing of vulnerability and personal imperfections in the clinical setting., Conclusions: Co-constructive patient simulation provides an alternative multistage and multimodal approach to traditional SP simulation sessions that can adapt iteratively and in real time to new clinical vicissitudes and challenges This learner-centered model holds promise to enrich simulation-based education by fostering autonomous, meaningful, and relevant experiences that are in alignment with trainees' self-identified learning goals., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Society for Simulation in Healthcare.)

Background: There is a paucity of literature describing how surgeons (either novice or expert) mentally prepare to carry out a surgical procedure. This paper focuses on these processes, and is part of a larger piece of research based on the Royal Australasian College of Surgeons (RACS) Clinical Decision Making model., Methods: Interviews were conducted over a 3-year period with registrars, trainees, fellows and consultants in the Department of Surgery at one large regional hospital in Victoria. Analysis began from the first interview with no pre-conceived codes. Emerging themes were drawn from participants' interpretation of their experiences. Further information was obtained during discussions in theatre while patients were being prepared for surgery., Results: The findings show that the process of rehearsal changes as a surgeon gains more experience in a procedure. A 'novice' relies on external sources of information, for example textbooks and videos. After participating in a number of similar procedures their reliance gradually moves to their own sensory memories. Surgeons at all levels of experience discuss their preparations with peers, colleagues, senior clinicians, and where appropriate, with members of other disciplines., Conclusion: These findings offer insight into how surgeons, at different levels of experience, prepare for a procedure. These understandings have the potential to improve the teaching and learning of this essential component of surgical practice., (© 2021 Royal Australasian College of Surgeons.)

Background: Problem-based learning (PBL) is classified as a collaborative learning approach, wherein students learn while contributing meaning to experiences and interactions with others. An important theoretical fundament of PBL is social interdependence theory (SIT) because positive social interdependence within a group has been found to be key to better learning performance and future attitudes towards team practice. However, most previous studies in health professions education focused on cognitive outcomes, and few studies have focused on collaborative behaviors in PBL groups. The lack of this empirical insight makes implementation of PBL difficult, especially in contexts where there is limited experience with collaborative learning. Therefore, the aim of this study was to elucidate what promotes or hinders positive social interdependence and how the attributes work during PBL., Methods: We conducted four focus groups among clinical year medical students (n = 26) who participated in PBL tutorials in the formal curriculum. We asked semi-structured questions that corresponded with the overall concept of SIT. We analyzed the transcript using constructivist grounded theory and developed a model to explain contextual attributes that promote or hinder positive social interdependence in PBL., Results: Two contextual attributes of "academic inquisition" and "desire for efficiency" affect social interdependence among a student group in PBL. Academic inquisition is students' desire to engage in their academic learning, and desire for efficiency is students' attitude toward learning as an imposed duty and desire to complete it as quickly as possible. These attributes are initially mutually conflicting and constructing social interdependence through multiple steps including inquisition from a case, seeking efficient work, sharing interest in problem solving, expecting mutual contributions, and complementing learning objectives., Conclusion: These findings will contribute to understanding collaborative learning environments in PBL and may help explain contexts where PBL is less successful. The model can also be used as a tool to support innovation of PBL as collaborative learning.