Conversations with Medical Education – revamp and expansion

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The blog cum discussion board for the leading journal in research in medical education (Medical Education) has undergone a makeover and expansion. The blog will now encompass articles from The Clinical Teacher; the journal for practical application and best practices for teachers of and in clinical practice. Additionally, information from the parent organization of both journals (ASME) will be included.

The reason for this change is to provide added opportunity for the readerships of both journals to interact with each other and spur more ideas that will ultimately lead to better research and better practice in medical and clinical education. You will see a few important features on the blog, including:

  • New title: For those of you who pay attention to detail, you will notice a one-word change in the title of the blog. The web address (URL) remains the same at www.mededucconversations.com, but the title has changed from ‘Conversations with Medical Education’ to ‘Conversations in Medical Education’. The key change from ‘with’ to ‘in’ shows the blog is no longer simply conversations with one journal.
  • New look: The color scheme and layout has changed to reflect the broader coverage of the blog that includes information streaming in from the two journals and ASME.
  • New categories: Blog posts are now organized via a ‘table of contents’ of sorts, that allows you to easily find the type of information you’re looking for. You can still use the Search box in the upper right to search for specific keywords. Categories are listed below.
  1. Article Abstracts: This category links to all blog posts that simply contain the title and abstract of the article in the journal issues.
  2. Comments on articles: This category links to guest blog posts on specific articles in the journals. Guest blog posts are provided by invited authors and the e-Council for the journals on a monthly basis.
  3. Meetings: This category links to posts about virtual meetings, such as journal clubs held via Twitter, and to meetings facilitated by ASME.
  4. Virtual Issues: This category links to posts that draw together articles around a common theme from across multiple issues or volumes within a journal, or across the two journals.

As always, the benefit to you, the reader, is best when you join in active conversation with your colleagues via the ‘Comment’ bubble that is next to the title of every post. Comments are moderated to keep spam and advertisements out of the way, but this should not impede a free flow of ideas around different approaches, clarifying questions, constructive feedback, and sharing of experiences relating to the topics in the post. Go ahead; join the conversation.

Joshua Jacobs, MD

e-Editor

Overview of the world’s medical schools: an update

To read on journal website, click here.

Robbert J Duvivier, John R Boulet, Amy Opalek, Marta van Zanten and John Norcini

Context

That few data are available on the characteristics of medical schools or on trends within medical education internationally constitutes a major challenge when developing strategies to address physician workforce shortages. Quality and up-to-date information is needed to improve health and education policy planning.

Methods

We used publicly available data from the International Medical Education Directory and Avicenna Directories, and an internal education programme database to gather data on medical education provision worldwide. We sent a semi-structured questionnaire to a selection of 346 medical schools, of which 218 (63%) in 81 different countries or territories replied. We contacted ministries of health, national agencies for accreditation or similar bodies to clarify inconsistencies among sources. We identified key informants to obtain country-level specific information. Descriptive statistics were used to analyse current medical school data by country.

Results

There are about 2600 medical schools worldwide. The countries with the largest numbers of schools are India (n = 304), Brazil (n = 182), the USA (n = 173), China (n = 147) and Pakistan (n = 86). One-third of all medical schools are located in five countries and nearly half are located in 10 countries. Of 207 independent states, 24 have no medical school and 50 have only one. Regionally, numbers of citizens per school differ: the Caribbean region has one school per 0.6 million population; the Americas and Oceania each have one school per 1.2 million population; Europe has one school per 1.8 million population; Asia has one school per 3.5 million population, and Africa has one school per 5.0 million population. In 2012, on average, there were 181 graduates per medical school.

Conclusions

The total number and distribution of medical schools around the world are not well matched with existing physician numbers and distribution. The collection and aggregation of medical school data are complex and would benefit from better information on local recognition processes. Longitudinal comparisons are difficult and subject to several sources of error. The consistency and quality of medical school data need to be improved to accurately document potential supply; one example of such an advancement is the World Directory of Medical Schools.

The good and bad of group conformity: a call for a new programme of research in medical education

To read on journal website, click here.

Tanya N Beran, Alyshah Kaba, Jeff Caird and Kevin McLaughlin

Context

Given that a significant portion of medical education occurs in various social settings (small groups, large classes, clinical environments), it is critical to examine how group members interact. One type of influence on these interactions is conformity, whereby an individual changes his or her own behaviour to match incorrect responses of others in a group. Conformity to peer pressure has been replicated in experimental research conducted in many countries over the last 60 years. There is newly emerging empirical evidence of this effect in medical education, suggesting that subtle motivations and pressures within a group may prevent students from challenging or questioning information that seems incorrect.

Objectives

This narrative review aims to present an overview of theory and findings in research into conformity in the fields of social psychology, business, sociology and aviation theory to demonstrate its direct relevance to medical education and the health professions.

Methods

We searched online databases (MEDLINE, PubMed, PsycINFO and ProQuest) from the University of Calgary catalogue. We also searched citations in articles reviewed and references provided by colleagues. We limited our narrative review to publications released between 1950 and 2012.

Results

Group conformity behaviour may be one of a number of communication challenges associated with interprofessional care, and may represent a factor contributing to the burden of adverse events. This paper calls for a new programme of research into conformity in medical education that provides systematic empirical evidence of its relevance and applications in education, health care and practice.

Conclusions

This review reveals decades of anecdotal and empirical evidence that conformity is a pervasive phenomenon across disciplines. Further research is needed to elucidate which situations pose the greatest risk for the occurrence of conformity, how to manage it in practice and its implications for patient safety.

‘You’re certainly relatively competent’: assessor bias due to recent experiences

Online abstract click here

Peter Yeates, Paul O’Neill, Karen Mann and Kevin W Eva

Context

A recent study has suggested that assessors judge performance comparatively rather than against fixed standards. Ratings assigned to borderline trainees were found to be biased by previously seen candidates’ performances. We extended that programme of investigation by examining these effects across a range of performance levels. Furthermore, we investigated whether confidence in the rating assigned predicts susceptibility to manipulation and whether prompting consideration of typical performance lessens the influence of recent experience.

Methods

Consultant doctors were randomised to groups within an internet experiment. The descending performance group judged videos of Foundation Year 1 (F1; postgraduate Year 1) doctors in descending order of proficiency; the ascending performance group judged the same videos in ascending order. For all videos, participants rated: (i) trainee competence; (ii) rater confidence and (iii) percentage better (the percentage of other F1 doctors who would perform better on the same task).

Results

Overall, the descending performance group assigned lower scores than the ascending performance group (2.97 [95% confidence interval 2.73–3.20] versus 3.50 [95% confidence interval 3.25–3.74]; F(1,47) = 9.80, p = 0.003, = 0.52). Pairwise comparisons showed differences were significant for good and borderline performances. The percentage better ratings showed a similar pattern (descending performance mean = 57.4 [95% confidence interval 52.5–62.3], ascending performance mean = 43.4 [95% confidence interval 38.4–48.5];F(1, 46) = 16.0, p < 0.001, = 0.67). Confidence ratings did not vary by level of performance and showed no relationship with the effect of group.

Discussion

Assessors’ judgements showed contrast effects at both good and borderline performance levels. Findings suggest that assessors use normative rather than criterion-referenced decision making while judging, and that the norms referenced are weakly represented in memory and easily influenced. Confidence ratings suggested a lack of insight into this phenomenon. Raters’ judgements could be importantly influenced in ways that are unfair to candidates.

Sharing teaching and learning resources: perceptions of a university’s faculty members

Online abstract click here

Stephen Maloney, Alan Moss, Jennifer Keating, George Kotsanas and Prue Morgan

Objectives

Improving efficiencies in the education sector via the sharing of resources is currently the source of much interest and investment within Australia and throughout the world. Despite the development of multiple educational resource repositories worldwide, educators seldom use repositories to share materials. Interprofessional sharing is similarly scarce. This research was designed to identify staff perceptions about inter-departmental sharing of teaching and learning resources within a university faculty.

Methods

Representatives were recruited over a 2-week period from four campuses of a university, spanning six departments. Participants took part in two focus groups and six semi-structured interviews. A thematic analysis was undertaken by two independent researchers.

Results

Five key themes emerged: the benefits of electronic resources for improving student education; perceptions of sharing; perceptions of ownership; the ethical use of resources and digital repositories; the requirements for adoption.

Conclusions

Our research confirms that educators believe interprofessional resource sharing to be beneficial and appropriate. However, concerns that resources are of insufficient quality or will be incorrectly attributed surfaced as barriers to sharing. Poor understanding and ambiguity surrounding intellectual property rights highlighted the need for repository communities to be sufficiently educated. Developing a commonly agreed metadata and labelling system, and linking with existing infrastructure, will enhance the impact of a learning object repository. Providing avenues for sharing, such as resource repositories, may assist in aligning education with the well-established process of peer review utilised by the research community, improving resource quality through exposure to others’ perspectives and feedback. Furthermore, the increased accountability, restriction and familiarity of repositories may prove beneficial in encouraging sharing.

Supervising incoming first-year residents: faculty expectations versus residents’ experiences

To read on journal website, click here.

Claire Touchie, André De Champlain, Debra Pugh, Steven Downing and Georges Bordage

Context

First-year residents begin clinical practice in settings in which attending staff and senior residents are available to supervise their work. There is an expectation that, while being supervised and as they become more experienced, residents will gradually take on more responsibilities and function independently.

Objectives

This study was conducted to define ‘entrustable professional activities’ (EPAs) and determine the extent of agreement between the level of supervision expected by clinical supervisors (CSs) and the level of supervision reported by first-year residents.

Methods

Using a nominal group technique, subject matter experts (SMEs) from multiple specialties defined EPAs for incoming residents; these represented a set of activities to be performed independently by residents by the end of the first year of residency, regardless of specialty. We then surveyed CSs and first-year residents from one institution in order to compare the levels of supervision expected and received during the day and night for each EPA.

Results

The SMEs defined 10 EPAs (e.g. completing admission orders, obtaining informed consent) that were ratified by a national panel. A total of 113 CSs and 48 residents completed the survey. Clinical supervisors had the same expectations regardless of time of day. For three EPAs (managing i.v. fluids, obtaining informed consent, obtaining advanced directives) the level of supervision reported by first-year residents was lower than that expected by CSs (p < 0.001) regardless of time of day (i.e. day or night). For four more EPAs (initiating the management of a critically ill patient, handing over the care of a patient to colleagues, writing a discharge prescription, coordinating a patient discharge) differences applied only to night-time work (p ≤ 0.001).

Conclusions

First-year residents reported performing EPAs with less supervision than expected by CSs, especially during the night. Using EPAs to guide the content of the undergraduate curriculum and during examinations could help better align CSs’ and residents’ expectations about early residency supervision.

Feedback in action within bedside teaching encounters: a video ethnographic study

To read on journal website, click here.

Chantelle Rizan, Christopher Elsey, Thomas Lemon, Andrew Grant and Lynn V Monrouxe

Context

Feedback associated with teaching activities is often synonymous with reflection on action, which comprises the evaluative assessment of performance out of its original context. Feedback in action (as correction during clinical encounters) is an underexplored, complementary resource facilitating students’ understanding and learning.

Objectives

The purpose of this study was to explore the interactional patterns and correction modalities utilised in feedback sequences between doctors and students within general practice-based bedside teaching encounters (BTEs).

Methods

A qualitative video ethnographic approach was used. Participants were recorded in their natural settings to allow interactional practices to be contextually explored. We examined 12 BTEs recorded across four general practices and involving 12 patients, four general practitioners and four medical students (209 minutes and 20 seconds of data) taken from a larger corpus. Data analysis was facilitated by Transana video analysis software and informed by previous conversation analysis research in ordinary conversation, classrooms and health care settings.

Results

A range of correction strategies across a spectrum of underlying explicitness were identified. Correction strategies classified at extreme poles of this scale (high or low explicitness) were believed to be less interactionally effective. For example, those using abrupt closing of topics (high explicitness) or interactional ambiguity (low explicitness) were thought to be less effective than embedded correction strategies that enabled the student to reach the correct answer with support.

Conclusions

We believe that educators who are explicitly taught linguistic strategies for how to manage feedback in BTEs might manage learning more effectively. For example, clinicians might maximise learning moments during BTEs by avoiding abrupt or ambiguous feedback practices. Embedded correction strategies can enhance student participation by guiding students towards the correct answer. Clinician corrections can sensitively manage student face-saving by minimising the exposure of student error to patients. Furthermore, we believe that the effective practices highlighted by our analysis might facilitate successful transformation of feedback in action into feedback for action.

 

‘We’ not ‘I’: health advocacy is a team sport

To read on journal website, click here.

Maria Hubinette, Sarah Dobson, Stephane Voyer and Glenn Regehr

Context

Health advocacy, although recognised as a professional responsibility, is often seen as overwhelming, perhaps because it is framed conceptually as an activity that each physician should undertake alone rather than as a collaborative process. In the context of a study exploring how effective physician health advocates conceptualise their roles and their activities related to health advocacy, we uncovered data that speak directly of the issue of whether the activities of health advocates are enacted as individual or collective pursuits.

Methods

We interviewed ten physicians, identified by others as effective health advocates, regarding their advocacy activities. We collected and analysed data in an iterative process, informed by constructivist grounded theory, continuously refining the interview framework and examining evolving themes. The final coding scheme was applied to all transcripts.

Results

Health advocacy was viewed by these physicians as a collective activity. This collective construction of advocacy presented in three ways: (i) as teamwork by interprofessional teams of individuals with clearly defined roles and functional, task-oriented goals; (ii) as a process involving networks of resources or people that can be accessed for both support and reinforcement, and (iii) as a process involving collaborative think-tanks in which members contribute different perspectives to enact collective problem solving at a conceptual level.

Conclusions

Effective health advocates do not conceptualise themselves as stand-alone experts who must do everything themselves. Their collective approach makes it possible for these physicians to incorporate health advocacy into their clinical practice. However, although conceptualising health advocacy as a collective activity may make it less daunting, this way of understanding health advocacy is not compatible with current formal descriptions of the associated competencies.

You’ve got to know the rules to play the game: how medical students negotiate the hidden curriculum of surgical careers

To read on journal website, click here.

Elspeth Hill, Katherine Bowman, Renée Stalmeijer and Jo Hart

Objectives

The hidden curriculum may be framed as the culture, beliefs and behaviours of a community that are passed to students outside formal course offerings. Medical careers involve diverse specialties, each with a different culture, yet how medical students negotiate these cultures has not been fully explored. Using surgery as a case study, we aimed to establish, first, whether a specialty-specific hidden curriculum existed for students, and second, how students encountered and negotiated surgical career options.

Methods

Using a constructivist grounded theory approach, we explored students’ thoughts, beliefs and experiences regarding career decisions and surgery. An exploratory questionnaire informed the discussion schedule for semi-structured individual interviews. Medical students were purposively sampled by year group, gender and career intentions in surgery. Data collection and analysis were iterative: analysis followed each interview and guided the adaptation of our discussion schedule to further our evolving model.

Results

Students held a clear sense of a hidden curriculum in surgery. To successfully negotiate a surgical career, students perceived that they must first build networks because careers information flows through relationships. They subsequently enacted what they learned by accruing the accolades (‘ticking the boxes’) and appropriating the dispositions (‘walking the talk’) of ‘future surgeons’. This allowed them to identify themselves and to be identified by others as ‘future surgeons’ and to gain access to participation in the surgical world. Participation then enabled further network building and access to careers information in a positive feedback loop. For some, negotiating the hidden curriculum was more difficult, which, for them, rendered a surgical career unattractive or unattainable.

Conclusions

Students perceive a clear surgery-specific hidden curriculum. Using a constructivist grounded theory approach, we have developed a model of how students encounter, uncover and enact this hidden curriculum to succeed. Drawing on concepts of Bourdieu, we discuss unequal access to the hidden curriculum, which was found to exclude many from the possibility of a surgical career.

Key-feature questions for assessment of clinical reasoning: a literature review

To read on journal website, click here.

Patricia Hrynchak, Susan Glover Takahashi and Marla Nayer

Objectives

Key-feature questions (KFQs) have been developed to assess clinical reasoning skills. The purpose of this paper is to review the published evidence on the reliability and validity of KFQs to assess clinical reasoning.

Methods

A literature review was conducted by searching MEDLINE (1946–2012) and EMBASE (1980–2012) via OVID and ERIC. The following search terms were used: key feature; question or test or tests or testing or tested or exam; assess or evaluation, and case-based or case-specific. Articles not in English were eliminated.

Results

The literature search resulted in 560 articles. Duplicates were eliminated, as were articles that were not relevant; nine articles that contained reliability or validity data remained. A review of the references and of citations of these articles resulted in an additional 12 articles to give a total of 21 for this review. Format, language and scoring of KFQ examinations have been studied and modified to maximise reliability. Internal consistency reliability has been reported as being between 0.49 and 0.95. Face and content validity have been shown to be moderate to high. Construct validity has been shown to be good using vector thinking processes and novice versus expert paradigms, and to discriminate between teaching methods. The very modest correlations between KFQ examinations and more general knowledge-based examinations point to differing roles for each. Importantly, the results of KFQ examinations have been shown to successfully predict future physician performance, including patient outcomes.

Conclusions

Although it is inaccurate to conclude that any testing format is universally reliable or valid, published research supports the use of examinations using KFQs to assess clinical reasoning. The review identifies areas of further study, including all categories of evidence. Investigation into how examinations using KFQs integrate with other methods in a system of assessment is needed.

Excellence in clinical teaching: knowledge transformation and development required

To read on journal website, click here.

David M Irby

Context

Clinical teachers in medicine face the daunting task of mastering the many domains of knowledge needed for practice and teaching. The breadth and complexity of this knowledge continue to increase, as does the difficulty of transforming the knowledge into concepts that are understandable to learners. Properly targeted faculty development has the potential to expedite the knowledge transformation process for clinical teachers.

Methods

Based on my own research in clinical teaching and faculty development, as well as the work of others, I describe the unique forms of clinical teacher knowledge, the transformation of that knowledge for teaching purposes and implications for faculty development.

Results

The following forms of knowledge for clinical teaching in medicine need to be mastered and transformed: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and learners, and (iv) knowledge integrated into teaching scripts. This knowledge is employed and conveyed through the parallel processes of clinical reasoning and clinical instructional reasoning. Faculty development can facilitate this knowledge transformation process by: (i) examining, deconstructing and practising new teaching scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching.

Conclusions

To become an excellent clinical teacher in medicine requires the transformation of multiple forms of knowledge for teaching purposes. These domains of knowledge allow clinical teachers to provide tailored instruction to learners at varying levels in the context of fast-paced and demanding clinical practice. Faculty development can facilitate this knowledge transformation process.