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BackgroundInternal Medicine (IM) subspecialty professional societies can provide valuable community, recognition, resources, and leadership opportunities that promote career success. Historically, this support focused on clinical and research dimensions of academic careers, but educational dimensions have gained more attention recently. This study explores how IM subspecialty professional societies support their clinician-educator members.MethodsUsing a qualitative study with two phases, the authors collected information from each IM subspecialty society's website about support for medical education. Using information from the first phase, we developed an interview guide for subspecialty society leaders. We used inductive thematic analysis to analyze interview transcripts.ResultsWebsite analysis identified various mechanisms used by several IM subspecialty societies to promote medical education. These included websites focused on medical education, dedicated medical education poster/abstract sessions at annual meetings, and strategies to promote networking among clinician-educators. Interviews with eight subspecialty society leaders about the professional societies' roles with respect to medical education yielded four main themes: [1] varying conceptions of "medical education" in relation to the society [2] strategies to advance medical education at the society level [3] barriers to recognizing medical education [4] benefits of clinician-educators to the societies. Integrating these themes, we describe recommended strategies for professional societies to better serve clinician-educators.ConclusionsWe explore how IM subspecialty societies attend to a growing constituency of clinician-educators, with increasing recognition and support of the career path but persistent barriers to its formalization. These conversations shed light on opportunities for professional subspecialty societies to better serve the needs of their clinician-educator members while also enabling these members to make positive contributions in return.

BackgroundDespite the widespread adoption of interprofessional simulation-based education (IPSE) in healthcare as a means to optimize interprofessional teamwork, data suggest that IPSE may not achieve these intended goals due to a gap between the ideals and the realities of implementation.MethodsWe conducted a qualitative case study that used the framework method to understand what and how core principles from guidelines for interprofessional education (IPE) and simulation-based education (SBE) were implemented in existing in situ IPSE programs. We observed simulation sessions and interviewed facilitators and directors at seven programs.ResultsWe found considerable variability in how IPSE programs apply and implement core principles derived from IPE and SBE guidelines with some principles applied by most programs (e.g., "active learning", "psychological safety", "feedback during debriefing") and others rarely applied (e.g., "interprofessional competency-based assessment", "repeated and distributed practice"). Through interviews we identified that buy-in, resources, lack of outcome measures, and power discrepancies influenced the extent to which principles were applied.ConclusionsTo achieve IPSE's intended goals of optimizing interprofessional teamwork, programs should transition from designing for the ideal of IPSE to realities of IPSE implementation.

IntroductionMany medical schools engage students in health system improvement (HSI) efforts. Evaluation of these efforts often focuses on students' learning outcomes and rarely considers the impact on health systems, despite the significant commitment health systems make to these efforts. Our study identified and evaluated system-level outcomes of pre-clerkship medical students' engagement in HSI efforts.MethodsWe used an instrumental case study approach to examine the effects of pre-clerkship medical students' engagement in HSI projects as part of a 15-month experiential curriculum. We extracted data from 53 project summaries and posters completed during the 2017-18 academic year and follow-up survey data collected in May 2019 from physician coaches and health system professionals who mentored students, contributed to these projects, and worked in the clinical microsystems where the projects occurred.ResultsWe identified three categories and ten indicators of health system outcomes relevant to medical student engagement in HSI. Using these indicators, our evaluation found multiple benefits to the microsystems in which projects occurred. These included achievement of project aims, perceived immediate and sustained project impact on the health system, and development and implementation of projects with aims that aligned with national and health system priorities.ConclusionEvaluation of HSI curricula needs to include effects on health systems so that program design can optimize the experience for all involved. Our study offers a framework others can use to evaluate system-level effects of project-based HSI curricula and shows several ways in which students' engagement can add value to health systems.

ObjectiveWorkplace-based assessments (WBAs) are used in multiple surgical specialties to facilitate feedback to residents as a form of formative assessment. The validity evidence to support this purpose is limited and has yet to include investigations of how users interpret the assessment and make rating decisions (response processes). This study aimed to explore the validity evidence based on response processes for a WBA in surgery.DesignSemi-structured interviews explored the reasonings and strategies used when answering questions in a surgical WBA, the System for Improving and Measuring Procedural Learning (SIMPL). Interview questions probed the interpretation of the three assessment questions and their respective answer categories (level of autonomy, operative performance, case complexity). Researchers analyzed transcripts using directed qualitative content analysis to generate themes.SettingSingle tertiary academic medical center.ParticipantsEight residents and 13 faculty within the Department of Otolaryngology-Head and Neck Surgery participating in a 6-month pilot of SIMPL.ResultsWe identified four overarching themes that that characterized faculty and resident response processes while completing SIMPL: (1) Faculty and resident users had similar content-level interpretations of the questions and corresponding answer choices; (2) Users employed a variety of cognitive, behavioral, and emotional processes to make rating decisions; (3) Contextual factors influenced ratings; and (4) Tensions during interpretation contributed to rating uncertainty.ConclusionsResponse processes are a key source of evidence to support the validity for the formative use of WBAs. Evaluating response process evidence should go beyond basic content-level analysis as contextual factors and tensions that arise during interpretation also play a large role in rating decisions. Additional work and a continued critical lens are needed to ensure that WBAs can truly meet the needs for formative assessment.

BackgroundPediatric emergency medicine (PEM) physicians receive training in critical procedures, but these procedures are rare in practice. The literature on maintenance of procedural skills focuses on ways to practice (e.g., via simulation) and pays little attention to motivation's role. Understanding what motivates PEM physicians to maintain procedural skills can inform the design of supportive policies and interventions. Our study explores how PEM physicians conceptualize maintenance of procedural skills, what motivates them to maintain procedural skills, and barriers to procedural skill maintenance.MethodsThis was a qualitative study of 12 PEM faculty guided by the self-determination theory (SDT) of motivation. SDT describes a typology that distinguishes extrinsic and intrinsic motivation, with intrinsic motivation based on autonomy, competence, and relatedness. Interviews were transcribed and coded using constant-comparative technique, and interviews continued until thematic sufficiency was achieved.ResultsParticipants had difficulty defining procedural skill maintenance by specific criteria and expressed ambivalence about external standards for competence, noting the need to account for individual and local practice factors. Three themes characterizing participants' motivation for procedural skills maintenance included: (1) desire to provide optimal patient care and fear of unsuccessful performance (competence), (2) procedural competence as part of the identity of a PEM physician who teaches and performs procedures (competence and relatedness), and (3) desire for accessibility and choice of options in maintaining procedural skills (autonomy). Participants identified lack of opportunities, time, and support as barriers to motivation and skills maintenance.ConclusionSDT concepts were integral to understanding faculty motivation, and this highlights the need for prioritizing faculty autonomy, competence, and relatedness in designing supports for procedural skill maintenance. Our findings regarding the difficulty in defining maintenance of skills emphasize the need for further discussion and study of this topic.

Objective. This study aimed to enrich the Academy's understanding of pharmacy students' readiness for advanced pharmacy practice experiences (APPEs) by exploring the perspectives of three primary stakeholders: APPE students, APPE preceptors, and APPE faculty site directors.Methods. A descriptive qualitative study of APPE readiness was conducted using workplace learning as a guiding conceptual framework. Data were collected between March and September 2019 through semi-structured focus groups and interviews with students (five groups), preceptors (four groups), and faculty site directors (one group, two individual interviews). The data were analyzed using directed content analysis.Results. Participants described APPE readiness as a multifaceted construct comprised of four themes: learner characteristics, participation in workplace activities, relationship-building, and workplace practices to orient and support students. While all participants addressed each category, faculty site directors and preceptors tended to focus on learner characteristics, while students emphasized their participation in the workplace and relationship building.Conclusion. Knowledge is widely recognized as a requirement for APPE readiness. This study identified learner characteristics, workplace participation, and relational skills as additional requirements. Some of these criteria are challenging to assess prior to APPEs, which makes orienting students both prior to and at the start of APPEs particularly important to support readiness. Thus, a comprehensive review of APPE readiness might also include assessing the readiness of workplaces, administrators, and preceptors for APPE students.

Habits of inquiry are considered an essential component of the modern physician's profile. These habits drive physicians to recognize and address the continuous challenges inherent to the practice of medicine; consequently, they meet the aims of better patient-centered care, better health of communities, and improved functioning of the health system. Many medical schools have endeavored to integrate inquiry into their curricula as a means of supporting development of adaptive expertise, a construct that encompasses habits of inquiry. However, the diversity of conceptualizations of inquiry has resulted in correspondingly diverse instructional implementations. Much of the emphasis has been on inquiry methods (e.g., engagement in research projects, courses in research methods and statistics), but the learners' inquiry disposition and its essential attitude component have received little attention in instruction and assessment. The authors propose that both inquiry methods and attitude need to be developed explicitly and simultaneously to prepare physicians to successfully be willing and able to address the challenges of today's health care environment. Because attitudes are established predictors of behavior, a positive inquiry attitude may be the ultimate determinant of physicians' engagement in behaviors of adaptive expertise (i.e., recognizing when learned procedures do not apply, and learning or inventing effective solutions). Addressing the attitude toward inquiry as early as possible in medical school is critical because strong attitudes are difficult to modify. Thus, a curriculum that supports positive inquiry attitude formation and strengthening will carry well beyond medical school and residency training.

Health professionals' roles and scopes often overlap, creating a need for role clarity in interprofessional teamwork. Yet, such clarity does not mean roles are fixed within teams and some literature suggests role flexibility can enhance team functioning. Interprofessional practice competencies and learning activities often emphasize knowledge and definition of roles, but rarely attend to the dynamic nature of roles and influential contextual factors. This study explores role fluidity in interprofessional student groups using an activity theory framework. Using a collective instrumental case study approach, the authors examine the fluidity of one physical therapy (PT) student's role within 3 different interprofessional (medical, pharmacy, PT) student groups completing nursing home patient care plans. Field notes, group debriefing interviews, and care plans were collected and coded from all care planning sessions. Codes mapped to group-specific activity systems that compared role-influencing interactions and tensions. The PT student's role fluidity varied in each group's activity system, influenced primarily by system tensions from implicit rules (e.g., encouraging questions), division of labor (e.g., rigid profession-based task assignment), and tool use (e.g., computers). Attention to modifiable system elements, such as tool use and explicit rules of inclusivity, could foster role fluidity and improve interprofessional teamwork and learning environments.

The article in Clinical Teacher explores the concept of transferability in qualitative research, focusing on applicability, resonance, and theoretical engagement. Authors discuss how transferability can be applied in education scholarship, using examples from innovative educational programs and qualitative studies in different contexts. The authors emphasize the importance of considering diverse cultural perspectives and the impact of transferability on health professions education scholarship. The article concludes by providing guidance for researchers to enhance the transferability of their work and communicate its relevance more clearly. [Extracted from the article]

Transferability is commonly identified as a quality criterion for qualitative research. This criterion was introduced by Lincoln and Guba to describe the degree to which a study's findings can be transferred to other contexts, settings or respondents. In this How To paper, we present a more nuanced, multidimensional view of transferability and explain relevant concepts, reflexive approaches and specific techniques to guide researchers in discussing transferability. We identify three dimensions of transferability for use in many approaches to qualitative research: applicability, resonance and theoretical engagement. Transferability as applicability relates to providing sufficient information for readers to evaluate the relevance of findings to other contexts. Transferability as resonance requires the researcher to present the research in a way that evokes a sense of familiarity or shared experience. Transferability as theoretical engagement refers to ways the researcher uses theory to frame a problem, connects findings to existing constructs and/or proposes a model or theory that could explain a process or phenomenon. We encourage researchers to consider all three dimensions of transferability when developing and presenting their work, keeping in mind that some dimensions may be more relevant than others based on study methodology and project goals. [ABSTRACT FROM AUTHOR]

When physicians transition patients, the physician taking over may change the diagnosis. Such a change could serve as an important source of clinical feedback to the prior physician. However, this feedback may not transpire if the current physician doubts the prior physician's receptivity to the information. This study explored facilitators of and barriers to feedback communication in the context of patient care transitions using an exploratory sequential, qualitative to quantitative, mixed methods design. Twenty-two internal medicine residents and hospitalist physicians from two teaching hospitals were interviewed and data were analyzed thematically. A prominent theme was participants' reluctance to communicate diagnostic changes. Participants perceived case complexity and physical proximity to facilitate, and hierarchy, unfamiliarity with the prior physician, and lack of relationship to inhibit communication. In the subsequent quantitative portion of the study, forty-one hospitalists completed surveys resulting in 923 total survey responses. Multivariable analyses and a mixed-effects model were applied to survey data with anticipated receptivity as the outcome variable. In the mixed-effects model, four factors had significant positive associations with receivers' perceived receptivity: (1) feedback senders' time spent on teaching services ([beta] = 0.52, p = 0.02), (2) receivers' trustworthiness and clinical credibility ([beta] = 0.49, p < 0.001), (3) preference of both for shared work rooms ([beta] = 0.15, p = 0.006), and (4) receivers being peers ([beta] = 0.24, p < 0.001) or junior colleagues ([beta] = 0.39, p < 0.001). This study suggests that anticipated receptivity to feedback about changed clinical decisions affects clinical communication loops. Without trusting relationships and opportunities for low risk, casual conversations, hospitalists may avoid such conversations.

At a time when cognitive and behavioral theories dominated the landscape of learning theories, Lave and Wenger's situated learning theory (SLT) opened new territory by illuminating social and cultural learning processes. Many researchers and educators in the health professions embraced this theory, but few have considered how SLT has been used and what has been learned or improved through its use in health professions education (HPE). In this scoping review, the authors examine these questions and consider opportunities for future work with SLT in HPE. The authors followed Levac's modified scoping review framework. They conducted a search of CINAHL, ERIC, PubMed, Scopus, and Web of Science for articles referencing SLT or related concepts in HPE between 2006 and 2016. Two reviewers screened all titles and abstracts, then screened full text for inclusion based on substantive treatment of SLT. Two authors extracted, analyzed and synthesized data from the final set of 193 articles. The authors identified two patterns of theory use. One sought an understanding of social learning processes in a specific context. The other aimed to design and/or evaluate interventions associated with communities of practice. These patterns are similar to other literatures (e.g., general education, healthcare, and organizational development) and, according to Lave and Wenger, may reflect confusion about the purpose, stance, and terminology of SLT. The authors discuss their findings in relation to primary source literature and consider opportunities for HPE researchers to employ and contribute to SLT going forward.

ContextTransitions of patient care responsibility occur frequently between physicians. Resultant discontinuities make it difficult for physicians to observe clinical outcomes. Little is known about what physicians do to overcome the practical challenges to learning these discontinuities create. This study explored physicians' activities in practice as they sought follow-up information about patients.MethodsUsing a constructivist grounded theory approach, semi-structured interviews with 18 internal medicine hospitalist and resident physicians at a single tertiary care academic medical center explored participants' strategies when deliberately conducting follow-up after they transitioned responsibility for patients to other physicians. Following open coding, the authors used activity theory (AT) to explore interactions among the social, cultural and material influences related to follow-up.ResultsThe authors identified three themes related to follow-up: (i) keeping lists to track patients, (ii) learning to create tracking systems and (iii) conducting follow-up. Analysis of participants' follow-up processes as an activity system highlighted key tensions in the system and participants' work adaptations. Tension within functionality of electronic health records for keeping lists (tools) to find information about patients' outcomes (object) resulted in using paper lists as workarounds. Tension between paper lists (tools) and protecting patients' health information (rules) led to rule-breaking or abandoning activities of locating information. Finding time to conduct desired follow-up produced tension between this and other activity systems.ConclusionIn clinical environments characterised by discontinuity, lists of patients served as tools for guiding patient care follow-up. The authors offer four recommendations to address the tensions identified through AT: (i) optimise electronic health record tracking systems to eliminate the need for paper lists; (ii) support physicians' skill development in developing and maintaining tracking systems for follow-up; (iii) dedicate time in physicians' work schedules for conducting follow-up; and (iv) engage physicians and patients in determining guidelines for longitudinal tracking that optimise physicians' learning and respect patients' privacy.

PurposePhysicians routinely transition responsibility for patient care to other physicians. When transitions of responsibility occur before the clinical outcome is known, physicians may lose opportunities to learn from the consequences of their decision making. Sometimes curiosity about patients does not end with the transition and physicians continue to follow them. This study explores physicians' motivations to follow up after transitioning responsibilities.MethodUsing a constructivist grounded theory approach, the authors conducted 18 semistructured interviews in 2016 with internal medicine hospitalist and resident physicians at a single tertiary care academic medical center. Constant comparative methods guided the qualitative analysis, using motivation theories as sensitizing constructs.ResultsThe authors identified themes that characterized participants' motivations to follow up. Curiosity about patients' outcomes determined whether or not follow-up occurred. Insufficient curiosity about predictable clinical problems resulted in the choice to forgo follow-up. Sufficient curiosity due to clinical uncertainty, personal attachment to patients, and/or concern for patient vulnerability motivated follow-up to fulfill goals of knowledge building and professionalism. The authors interpret these findings through the lenses of expectancy-value (EVT) and self-determination (SDT) theories of motivation.ConclusionsParticipants' curiosity about what happened to their patients motivated them to follow up. EVT may explain how participants made choices in time-pressured work settings. SDT may help interpret how follow-up fulfills needs of relatedness. These findings add to a growing body of literature endorsing learning environments that consider task-value trade-offs and support basic psychological needs of autonomy, competency, and relatedness to motivate learning.

BackgroundProviding a robust continuity clinic experience is difficult due to uneven distribution of resident time. Immersion experiences early in training may improve residents' learning experiences.ObjectiveWe designed and implemented a continuity immersion experience to improve internal medicine interns' satisfaction and confidence with their outpatient skills, and we evaluated the timing of the experience and its benefits for learners.MethodsTwo cohorts of interns at 1 academic institution participated in a 3-week immersion block (during the first or second quarter of the intern year). Interns were surveyed twice about satisfaction and confidence. Analysis included independent and paired sample t tests to compare interns' responses pre- and postimmersion, and to evaluate effects over time.ResultsA total of 124 interns completed the immersion, with a survey response rate of 61%. Interns' self-rated confidence on a 5-point Likert scale improved significantly compared with preimmersion in the areas of medical knowledge and confidence with their electronic health record and communication skills (P ≤ .010 for all assessments). Interns reported high satisfaction with continuity clinic following immersion (cohort 1: 4.5 ± 0.54; cohort 2: 4.3 ± 0.68; on a 5-point scale with 5 = very satisfied). Improvements in knowledge, skills, and satisfaction in cohort 1 were sustained over 3 months.ConclusionsA 3-week immersion experience in the first 6 months of residency improved interns' confidence in ambulatory content areas and satisfaction with clinic.

Introduction: Qualitative approaches have flourished in medical education research. Many research articles use the term 'lived experience' to describe the purpose of their study, yet we have noticed contradictory uses and misrepresentations of this term. In this conceptual paper, we consider three sources of these contradictions and misrepresentations: (1) the conflation of perspectives with experiences; (2) the conflation of experience with lived experience; and (3) the conflation of researching lived experience with phenomenology. We offer suggestions to facilitate more precise use of terminology. Argument: Our starting point is to free researchers from unnecessary shackles: Not every problem in medical education should be studied through experience, nor should every study of experience be phenomenological. Data based on participants' perceptions, beliefs, opinions and thoughts, while based on reflections of experiences, are not in and of themselves accounts of experience. Lived experiences are situated, primal and pre‐reflective; perspectives are more abstract. Lived experience—as opposed to experiences as such—deeply attune to bodies, relationality, space and time. There is also a difference between experiences as lived, how a person makes sense of these and what the researcher interprets and represents. Phenomenology is a meaningful approach to the study of lived experience, but other approaches, such as narrative inquiry and self‐study, can also offer useful avenues for undertaking this type of research. Discussion We aim to broaden researchers' scope with this paper and equip researchers with the information they need to be clear about the meaning and use of the terms experience and lived experience. We also hope to open new methodological possibilities for researching experiences as lived and, through highlighting tensions, to prompt researchers of lived experience to strive for ontological closeness and resonance. Interested in researching lived experiences? What are they anyway? Find out in this paper where the authors dive into complexity and offer explanation to enable more precise use of terminology. #meded [ABSTRACT FROM AUTHOR]

BackgroundMedical students often struggle to apply their nascent clinical skills in clerkships. While transitional clerkships can orient students to new roles and logistics, students may benefit from developing clinical skills in inpatient environments earlier in their curriculum to improve readiness for clerkships.InterventionOur four- to six-session elective provides pre-clerkship students with individualized learning in the inpatient setting with the aim of improving clerkship preparedness. Students work one-on-one with faculty who facilitate individualized learning through mentoring, deliberate practice, and directed feedback. Second-year medical students are placed on an attending-only, traditionally 'non-teaching' service in the hospital medicine division of a Veterans Affairs (VA) hospital for half-day sessions. Most students self-select into the elective following a class-wide advertisement. The elective also accepts students who are referred for remediation of their clinical skills.OutcomeIn the elective's first two years, 25 students participated and 47 students were waitlisted. We compared participant and waitlisted (non-participant) students' self-efficacy in several clinical and professional domains during their first clerkship. Elective participants reported significantly higher clerkship preparedness compared to non-participants in the areas of physical exam, oral presentation, and formulation of assessments and plans.ConclusionsStudents found the one-on-one feedback and personalized attention from attending physicians to be a particularly useful aspect of the course. This frequently cited benefit points to students' perceived needs and the value they place on individualized feedback. Our innovation harnesses an untapped resource - the hospital medicine 'non-teaching' service - and serves as an attainable option for schools interested in enhancing early clinical skill-building for all students, including those recommended for remediation.AbbreviationsA&P: Assessment and plan; H&P: History and physical; ILP: Individual learning plan.

PurposeProfessional and governmental organizations recommend an ideal US physician workforce composed of at least 40 % primary care physicians. They also support primary care residencies to promote careers in primary care. Our study examines the relationship between graduation from a primary care or categorical internal medicine residency program and subsequent career choice.MethodsWe conducted a cross-sectional electronic survey of a cohort of internal medicine residency alumni who graduated between 2001 and 2010 from a large academic center. Our primary predictor was graduation from a primary care versus a categorical internal medicine program and our primary outcome is current career role. We performed chi-square analysis comparing responses of primary care and categorical residents.ResultsWe contacted 481 out of 513 alumni, of whom 322 responded (67 %). We compared 106 responses from primary care alumni to 169 responses from categorical alumni. Fifty-four percent of primary care alumni agreed that the majority of their current clinical work is in outpatient primary care vs. 20 % of categorical alumni (p < 0.001). While 92.5 % of primary-care alumni were interested in a primary care career prior to residency, only 63 % remained interested after residency. Thirty of the 34 primary care alumni (88 %) who lost interest in a primary care career during residency agreed that their ambulatory experience during residency influenced their subsequent career choice.ConclusionsA higher percentage of primary care alumni practice outpatient primary care as compared to categorical alumni. Some alumni lost interest in primary care during residency. The outpatient clinic experience may impact interest in primary care.