Eight ways to get a grip on validity as a social imperative.

Validity as a social imperative foregrounds the social consequences of assessment and highlights the importance of building quality into the assessment development and monitoring processes. Validity as a social imperative is informed by current assessment trends such as programmatic-, longitudinal-, and rater-based assessment, and is one of the conceptualizations of validity currently at play in the Health Professions Education (HPE) literature. This Black Ice is intended to help readers to get a grip on how to embed principles of validity as a social imperative in the development and quality monitoring of an assessment. This piece draws on a program of work investigating validity as a social imperative, key HPE literature, and data generated through stakeholder interviews. We describe eight ways to implement validation practices that align with validity as a social imperative.

La validité en tant qu'impératif social met de l'avant les conséquences de l'évaluation des apprentissages sur la société et souligne l'importance d'intégrer la qualité dans le développement et le monitoring de l'évaluation des apprentissages. La validité en tant qu'impératif social est influencée par les tendances actuelles en matière d'évaluation, telles que l'évaluation programmatique, longitudinale et l'évaluation par des évaluateurs. La validité en tant qu'impératif social fait partie des conceptualisations actuellement présentes dans les écrits scientifiques dans le contexte de la pédagogie des sciences de la santé. Ce texte a pour but d'aider les lecteurs à comprendre comment intégrer les principes de validité en tant qu'impératif social dans le développement et le suivi de qualité d'une évaluation. Cet article s'appuie sur un programme de recherche qui examine la validité en tant qu'impératif social, sur les écrits scientifiques en pédagogie des sciences de la santé et des données provenant d'entrevues avec différentes parties prenantes. Nous décrivons huit façons de mettre en œuvre des pratiques de validation qui sont en accord avec la validité en tant qu'impératif social.

Is There a Problem With Evidence in Health Professions Education?

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.

Magnitude and time to peak oxygenation effect of prone positioning in ventilated adults with COVID-19 related acute hypoxemic respiratory failure.

BACKGROUND: Prone positioning may improve oxygenation in acute hypoxemic respiratory failure and was widely adopted in COVID-19 patients. However, the magnitude and timing of its peak oxygenation effect remain uncertain with the optimum dosage unknown. Therefore, we aimed to investigate the magnitude of the peak effect of prone positioning on the PaO2 :FiO2 ratio during prone and secondly, the time to peak oxygenation. METHODS: Multi-centre, observational study of invasively ventilated adults with acute hypoxemic respiratory failure secondary to COVID-19 treated with prone positioning. Baseline characteristics, prone positioning and patient outcome data were collected. All arterial blood gas (ABG) data during supine, prone and after return to supine position were analysed. The magnitude of peak PaO2 :FiO2 ratio effect and time to peak PaO2 :FIO2 ratio effect was measured. RESULTS: We studied 220 patients (mean age 54 years) and 548 prone episodes. Prone positioning was applied for a mean (±SD) 3 (±2) times and 16 (±3) hours per episode. Pre-proning PaO2 :FIO2 ratio was 137 (±49) for all prone episodes. During the first episode. the mean PaO2 :FIO2 ratio increased from 125 to a peak of 196 (p < .001). Peak effect was achieved during the first episode, after 9 (±5) hours in prone position and maintained until return to supine position. CONCLUSIONS: In ventilated adults with COVID-19 acute hypoxemic respiratory failure, peak PaO2 :FIO2 ratio effect occurred during the first prone positioning episode and after 9 h. Subsequent episodes also improved oxygenation but with diminished effect on PaO2 :FIO2 ratio. This information can help guide the number and duration of prone positioning episodes.

Neuromuscular blockade and oxygenation changes during prone positioning in COVID-19.

PURPOSE: Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain. METHODS: Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position. RESULTS: We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO2:FiO2 (P/F ratio) during the first prone episode with NMBs reached 208 ± 63 mmHg compared with 161 ± 66 mmHg without NMBs (Δmean = 47 ± 5 mmHg) for an absolute increase from baseline of 76 ± 56 mmHg versus 55 ± 56 mmHg (padj < 0.001). The mean P/F ratio on return to the supine position was 190 ± 63 mmHg in the NMB group versus 141 ± 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 ± 58 mmHg versus 34 ± 56 mmHg (padj < 0.001). CONCLUSION: During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.

An exploration of values in medical school admissions processes: the interplay between contextual factors, admissions practices, and validity.

Medical school admissions is a contentious and high stakes selection activity. Many assessment approaches are available to support selection; but how are decisions about building, monitoring, and adapting admissions systems made? What shapes the processes and practices that underpin selection decisions? We explore how these decisions are made across several Canadian medical schools, and how values shape the creation, monitoring, and adaptation of admissions systems. Using phenomenography (a qualitative method suited to examining variability), the authors analyzed interviews with 10 current or previous heads of admissions from 10 different undergraduate medical education programs in Canada. Interviews were conducted in English and French, and data was collected between 2016 and 2017 (therefore participants no longer hold these roles). Data was coded and analyzed iteratively, focusing on identifying underlying values, and exploring how these values shape admissions practices and considerations for validity. Eight different intersecting values were identified. Of these, four were shared across all participants: critically questioning the process and tools, aiming for equity, striving for better, and embracing the challenges of change. The expression of these values depended on different contextual variables (e.g., geographic location, access to expertise, resource availability), and values shaped how admissions systems were built, enacted, and monitored for quality. Ultimately, values shaped: (1) admissions practices resulting in different candidates being offered admission, and (2) how arguments supporting score interpretation are built (i.e., validity). This study documents various values that influence admissions processes, practices, and quality monitoring. The values that shape what is assessed, how it is assessed, and how fair and defensible practices are conceptualized have significant impact, ultimately determining who is selected. These values-whether implicit or explicit-result in intended and unintended consequences in selection processes. However, these values are rarely explicitly examined and questioned, leaving it uncertain as to which consequences are the intended outcomes of deliberately chosen values, and which are unintended consequences of implicitly held values of admissions systems and their actors.

Digging Deeper, Zooming Out: Reimagining Legacies in Medical Education.

Although the wide-scale disruption precipitated by the COVID-19 pandemic has somewhat subsided, there are many questions about the implications of such disruptions for the road ahead. This year's Research in Medical Education (RIME) supplement may provide a window of insight. Now, more than ever, researchers are poised to question long-held assumptions while reimagining long-established legacies. Themes regarding the boundaries of professional identity, approaches to difficult conversations, challenges of power and hierarchy, intricacies of selection processes, and complexities of learning climates appear to be the most salient and critical to understand. In this commentary, the authors use the relationship between legacies and assumptions as a framework to gain a deeper understanding about the past, present, and future of RIME.

If we assess, will they learn? Students' perspectives on the complexities of assessment-for-learning.

Introduction: Assessment can positively influence learning, however designing effective assessment-for-learning interventions has proved challenging. We implemented a mandatory assessment-for-learning system comprising a workplace-based assessment of non-medical expert competencies and a progress test in undergraduate medical education and evaluated its impact. Methods: We conducted semi-structured interviews with year-3 and 4 medical students at McGill University to explore how the assessment system had influenced their learning in year 3. We conducted theory-informed thematic analysis of the data. Results: Eleven students participated, revealing that the assessment influenced learning through several mechanisms. Some required little student engagement (i.e., feed-up, test-enhanced learning, looking things up after an exam). Others required substantial engagement (e.g., studying for tests, selecting raters for quality feedback, using feedback). Student engagement was moderated by the perceived credibility of the system and of the costs and benefits of engagement. Credibility was shaped by students' goals-in-context: becoming a good doctor, contributing to the healthcare team, succeeding in assessments. Discussion: Our assessment system failed to engage students enough to leverage its full potential. We discuss the inherent flaws and external factors that hindered student engagement. Assessment designers should leverage easy-to-control mechanisms to support assessment-for-learning and anticipate significant collaborative work to modify learning cultures.

Introduction: L'évaluation peut influencer positivement l'apprentissage mais la conception de dispositifs d'évaluation pour l'apprentissage efficaces s'avère difficile. Nous avons implanté en formation prédoctorale un système obligatoire d'évaluation pour l'apprentissage comprenant une évaluation en milieu clinique des compétences transversales et un test de rendement progressif, puis évalué ses effets. Méthodes: Nous avons mené des entretiens semi-dirigés avec des étudiants en troisième et quatrième années de médecine à l'Université McGill pour explorer la manière dont le système d'évaluation avait influencé leur apprentissage au cours de la troisième année. Nous avons effectué une analyse thématique, informée par la théorie, des données. Résultats: Onze étudiants ont participé. Les résultats indiquent que l'évaluation a influencé leur apprentissage par le biais de plusieurs mécanismes différents. Certains d'entre eux nécessitaient une implication faible de la part de l'étudiant, comme l'identification des objectifs à atteindre (feed-up), l'apprentissage amélioré par les tests, la recherche d'informations après un examen. D'autres exigeaient une implication importante (par exemple, étudier pour les tests, sélectionner les évaluateurs pour obtenir une rétroaction de qualité, mettre à profit la rétroaction). L'implication des étudiants était modulée par leur perception des avantages et des inconvénients de s'impliquer, et de la crédibilité du système. Cette dernière était influencée par les objectifs-en-contexte des étudiants: devenir un bon médecin, contribuer à l'équipe soignante, réussir les épreuves d'évaluation. Discussion: Notre système d'évaluation n'a pas réussi à impliquer suffisamment les étudiants que pour réaliser son potentiel. Nous abordons les défauts inhérents au système ainsi que les facteurs externes qui ont entravé l'implication des apprenants. Pour implanter efficacement un dispositif d'évaluation pour l'apprentissage, les concepteurs d'évaluations devraient optimiser les mécanismes qui sont faciles à contrôler et être prêts à s'investir dans un important travail de collaboration pour changer les cultures d'apprentissage.

Nanograms of SARS-CoV-2 spike protein delivered by exosomes induce potent neutralization of both delta and omicron variants.

Exosomes are emerging as potent and safe delivery carriers for use in vaccinology and therapeutics. A better vaccine for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is needed to provide improved, broader, longer lasting neutralization of SARS-CoV-2, a more robust T cell response, enable widespread global usage, and further enhance the safety profile of vaccines given the likelihood of repeated booster vaccinations. Here, we use Capricor's StealthXTM platform to engineer exosomes to express native SARS-CoV-2 spike Delta variant (STX-S) protein on the surface for the delivery of a protein-based vaccine for immunization against SARS-CoV-2 infection. The STX-S vaccine induced a strong immunization with the production of a potent humoral immune response as demonstrated by high levels of neutralizing antibody not only against the delta SARS-CoV-2 virus but also two Omicron variants (BA.1 and BA.5), providing broader protection than current mRNA vaccines. Additionally, both CD4+ and CD8+ T cell responses were increased significantly after treatment. Quantification of spike protein by ELISA showed that only nanograms of protein were needed to induce a potent immune response. This is a significantly lower dose than traditional recombinant protein vaccines with no adjuvant required, which makes the StealthXTM exosome platform ideal for the development of multivalent vaccines with a better safety profile. Importantly, our exosome platform allows novel proteins, or variants in the case of SARS-CoV-2, to be engineered onto the surface of exosomes in a matter of weeks, comparable with mRNA vaccine technology, but without the cold storage requirements necessary for mRNA vaccines. The ability to utilize exosomes for cellular delivery of proteins, as demonstrated by STX-S, has enormous potential to revolutionize vaccinology by rapidly facilitating antigen presentation at an extremely low dose resulting in a potent, broad antibody response.

The impact of prior performance information on subsequent assessment: is there evidence of retaliation in an anonymous multisource assessment system?

Few studies have engaged in data-driven investigations of the presence, or frequency, of what could be considered retaliatory assessor behaviour in Multi-source Feedback (MSF) systems. In this study, authors explored how assessors scored others if, before assessing others, they received their own assessment score. The authors examined assessments from an established MSF system in which all clinical team members - medical students, interns, residents, fellows, and supervisors - anonymously assessed each other. The authors identified assessments in which an assessor (i.e., any team member providing a score to another) gave an aberrant score to another individual. An aberrant score was defined as one that was more than two standard deviations from the assessment receiver's average score. Assessors who gave aberrant scores were categorized according to whether their behaviour was preceded by: (1) receiving a score or not from another individual in the MSF system (2) whether the score they received was aberrant or not. The authors used a multivariable logistic regression model to investigate the association between the type of score received and the type of score given by that same individual. In total, 367 unique assessors provided 6091 scores on the performance of 484 unique individuals. Aberrant scores were identified in 250 forms (4.1%). The chances of giving an aberrant score were 2.3 times higher for those who had received a score, compared to those who had not (odds ratio 2.30, 95% CI:1.54-3.44, P < 0.001). Individuals who had received an aberrant score were also 2.17 times more likely to give an aberrant score to others compared to those who had received a non-aberrant score (2.17, 95% CI:1.39-3.39, P < 0.005) after adjusting for all other variables. This study documents an association between receiving scores within an anonymous multi-source feedback (MSF) system and providing aberrant scores to team members. These findings suggest care must be given to designing MSF systems to protect against potential downstream consequences of providing and receiving anonymous feedback.

Sodium Bicarbonate for Metabolic Acidosis in the ICU: Results of a Pilot Randomized Double-Blind Clinical Trial.

OBJECTIVES: To identify the best population, design of the intervention, and to assess between-group biochemical separation, in preparation for a future phase III trial. DESIGN: Investigator-initiated, parallel-group, pilot randomized double-blind trial. SETTING: Eight ICUs in Australia, New Zealand, and Japan, with participants recruited from April 2021 to August 2022. PATIENTS: Thirty patients greater than or equal to 18 years, within 48 hours of admission to the ICU, receiving a vasopressor, and with metabolic acidosis (pH < 7.30, base excess [BE] < -4 mEq/L, and Pa co2 < 45 mm Hg). INTERVENTIONS: Sodium bicarbonate or placebo (5% dextrose). MEASUREMENTS AND MAIN RESULT: The primary feasibility aim was to assess eligibility, recruitment rate, protocol compliance, and acid-base group separation. The primary clinical outcome was the number of hours alive and free of vasopressors on day 7. The recruitment rate and the enrollment-to-screening ratio were 1.9 patients per month and 0.13 patients, respectively. Time until BE correction (median difference, -45.86 [95% CI, -63.11 to -28.61] hr; p < 0.001) and pH correction (median difference, -10.69 [95% CI, -19.16 to -2.22] hr; p = 0.020) were shorter in the sodium bicarbonate group, and mean bicarbonate levels in the first 24 hours were higher (median difference, 6.50 [95% CI, 4.18 to 8.82] mmol/L; p < 0.001). Seven days after randomization, patients in the sodium bicarbonate and placebo group had a median of 132.2 (85.6-139.1) and 97.1 (69.3-132.4) hours alive and free of vasopressor, respectively (median difference, 35.07 [95% CI, -9.14 to 79.28]; p = 0.131). Recurrence of metabolic acidosis in the first 7 days of follow-up was lower in the sodium bicarbonate group (3 [20.0%] vs. 15 [100.0%]; p < 0.001). No adverse events were reported. CONCLUSIONS: The findings confirm the feasibility of a larger phase III sodium bicarbonate trial; eligibility criteria may require modification to facilitate recruitment.

Exosome-Based Multivalent Vaccine: Achieving Potent Immunization, Broadened Reactivity, and Strong T-Cell Responses with Nanograms of Proteins.

Currently approved vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have focused solely on the spike protein to provide immunity. The first vaccines were developed rapidly using spike mRNA delivered by lipid nanoparticles but required ultralow-temperature storage and have had limited immunity against variations in spike. Subsequently, protein-based vaccines were developed, which offer broader immunity but require significant time for development and the use of an adjuvant to boost the immune response. Here, exosomes were used to deliver a bivalent protein-based vaccine in which two independent viral proteins were used. Exosomes were engineered to express either SARS-CoV-2 delta spike (Stealth X-Spike [STX-S]) or the more conserved nucleocapsid (Stealth X-Nucleocapsid [STX-N]) protein on the surface. When administered as a single product (STX-S or STX-N) or in combination (STX-S+N), both STX-S and STX-N induced strong immunization with the production of potent humoral and cellular immune responses. Interestingly, these results were obtained with the administration of only nanograms of protein and without an adjuvant. In two independent animal models (mouse and rabbit), the administration of nanograms of the STX-S+N vaccine resulted in increased antibody production, potent neutralizing antibodies with cross-reactivity to other variants of spike, and strong T-cell responses. Importantly, no competition of immune responses was observed, allowing the delivery of nucleocapsid with spike to offer improved SARS-CoV-2 immunity. These data show that the StealthX exosome platform has the enormous potential to revolutionize vaccinology by combining the advantages of mRNA and recombinant protein vaccines into a superior, rapidly generated, low-dose vaccine resulting in potent, broader immunity. IMPORTANCE The pandemic emergency has brought to light the need for a new generation of rapidly developed vaccines that induce longer-lasting, potent, and broader immune responses. While the mRNA vaccines played a critical role during the emergency in reducing SARS-CoV-2 hospitalization rates and deaths, more efficient approaches are needed. A multivalent, protein-based vaccine delivered by exosomes could meet this urgent need due to the high speed of development, manufacturability, and the ability to produce a strong antibody response, with neutralizing antibodies and a strong T-cell response able to broadly combat viral infection with a minimum number of injections.

Pilot Study Evaluating Cross-Disciplinary Educational Material to Improve Patients' Knowledge of Palliative Radiation Therapy.

Palliative radiation therapy (PRT) is underutilized, partially due to misconceptions about its risks, benefits, and indications. The objective of this pilot study was to determine if patients with metastatic cancer would gain knowledge from educational material describing PRT and perceive it as useful in their care. A one-page handout conveying information about the purpose, logistics, benefits, risks, and common indications for PRT was offered to patients undergoing treatment for incurable, metastatic solid tumors in one palliative care clinic and four medical oncology clinics. Participants read the handout, then completed a questionnaire assessing its perceived value. Seventy patients participated between June and December 2021. Sixty-five patients (93%) felt they learned from the handout (40% learned "lots"), and 69 (99%) felt the information was useful (53% "very useful"). Twenty-one patients (30%) were previously unaware that PRT can relieve symptoms, 55 (79%) were unaware that PRT can be delivered in five treatments or less, and 43 (61%) were unaware that PRT usually has few side effects. Sixteen patients (23%) felt they currently had symptoms not being treated well enough, and 34 (49%) felt they had symptoms that radiation might help with. Afterwards, most patients felt more comfortable bringing symptoms to a medical oncologist's (n = 57, 78%) or radiation oncologist's (n = 51, 70%) attention. Patient-directed educational material about PRT, provided outside of a radiation oncology department, was perceived by patients as improving their knowledge and adding value in their care, independent of prior exposure to a radiation oncologist.

Learning strategy impacts medical diagnostic reasoning in early learners.

Relating learned information to similar yet new scenarios, transfer of learning, is a key characteristic of expert reasoning in many fields including medicine. Psychological research indicates that transfer of learning is enhanced via active retrieval strategies. For diagnostic reasoning, this finding suggests that actively retrieving diagnostic information about patient cases could improve the ability to engage in transfer of learning to later diagnostic decisions. To test this hypothesis, we conducted an experiment in which two groups of undergraduate student participants learned symptom lists of simplified psychiatric diagnoses (e.g., Schizophrenia; Mania). Next, one group received written patient cases and actively retrieved the cases from memory and the other group read these written cases twice, engaging in a passive rehearsal learning strategy. Both groups then diagnosed test cases that had two equally valid diagnoses-one supported by "familiar" symptoms described in learned patient cases, and one by novel symptom descriptions. While all participants were more likely to assign higher diagnostic probability to those supported by the familiar symptoms, this effect was significantly larger for participants that engaged in active retrieval compared to passive rehearsal. There were also significant differences in performance across the given diagnoses, potentially due to differences in established knowledge of the disorders. To test this prediction, Experiment 2 compared performance on the described experiment between a participant group that received the standard diagnostic labels to a group that received fictional diagnostic labels, nonsense words designed to remove prior knowledge with each diagnosis. As predicted, there was no effect of diagnosis on task performance for the fictional label group. These results provide new insight on the impact of learning strategy and prior knowledge in fostering transfer of learning, potentially contributing to expert development in medicine.

What is the Current State of Extended Reality Use in Otolaryngology Training? A Scoping Review.

OBJECTIVE: To map current literature on the educational use of extended reality (XR) in Otolaryngology-Head and Neck Surgery (OHNS) to inform teaching and research. STUDY DESIGN: Scoping Review. METHODS: A scoping review was conducted, identifying literature through MEDLINE, Ovid Embase, and Web of Science databases. Findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review checklist. Studies were included if they involved OHNS trainees or medical students who used XR for an educational purpose in OHNS. XR was defined as: fully-immersive virtual reality (VR) using head-mounted displays (HMDs), non-immersive and semi-immersive VR, augmented reality (AR), or mixed reality (MR). Data on device use were extracted, and educational outcomes were analyzed according to Kirkpatrick's evaluation framework. RESULTS: Of the 1,434 unique abstracts identified, 40 articles were included. All articles reported on VR; none discussed AR or MR. Twenty-nine articles were categorized as semi-immersive, none used occlusive HMDs therefore, none met modern definitions of immersive VR. Most studies (29 of 40) targeted temporal bone surgery. Using the Kirkpatrick four-level evaluation model, all studies were limited to level-1 (learner reaction) or level-2 (knowledge or skill performance). CONCLUSIONS: Current educational applications of XR in OHNS are limited to VR, do not fully immerse participants and do not assess higher-level learning outcomes. The educational OHNS community would benefit from a shared definition for VR technology, assessment of skills transfer (level-3 and higher), and deliberate testing of AR, MR, and procedures beyond temporal bone surgery. Laryngoscope, 133:227-234, 2023.

Action-project method: An approach to describing and studying goal-oriented joint actions.

CONTEXT: Practicing health professionals and educators frequently act together in an interdependent or joint capacity to reach goals. Teaching or learning a new skill or engaging with patients in shared decision-making exemplifies this joint and goal-directed nature of Health Professions Education (HPE) and practice. However, building a robust understanding of the complexity of action, and joint action in particular, in HPE or patient care remains a challenge because of a limited number of methodologies available within HPE research. METHODS: In this manuscript, we describe the Action-Project Method (A-PM) as a qualitative research approach that can be used to describe and understand goal-directed joint actions. A-PM is grounded in contextual action theory and is a methodology focussed on action as an object of study, as it is occurring. A-PM uses three distinct perspectives to understand goal-directed joint actions: observable behaviour, internal processes (i.e. reported thoughts and feelings) and the social meaning reflected in goals. Data collection in A-PM involves observations, interviews, recording of actions and a self-confrontation procedure-where participants watch video-recorded segments of action and reflect on their internal processes, describing what they were thinking or feeling as they were completing the action. Together, the rich data generated and the layered approach to analysis provide a means to better understand the joint actions embedded in complex systems and collaborative work. Furthermore, the participants are treated as equal partners within A-PM, ensuring data equity even when the research context includes hierarchical relationships. DISCUSSION: Given increasing recognition to the importance of teamwork, relationships, interdependence, complex environments and centring patient or learner voices, A-PM is a valuable research approach for HPE. A-PM deepens our research arsenal with an approach that focusses on interdependent dyads or teams and provides a deeper understanding for how individuals engage together in goal-oriented actions.