Workplace affordances and learning engagement in a Thai paediatric intensive care unit.

BACKGROUND: Workplace learning in critical care settings is complex and challenging. Research has explored learner-, teacher-, and context-related factors that influence medical residents' engagement in critical care workplaces in Western but not in non-Western cultures. This limits our understanding of workplace learning globally and how we can better support resident learning in diverse cultures. OBJECTIVE: To explore how paediatric residents engage in workplace learning in a Thai Paediatric Intensive Care Unit (PICU) and how this culturally situated workplace shapes their learning. METHODS: In this qualitative study, we recruited paediatric residents (n = 16) from a tertiary care hospital in Thailand for semi-structured interviews. We used reflexive thematic analysis to describe, analyse and interpret residents' experiences of workplace learning, and to capitalise on our own experience as an analytic resource. RESULTS: We constructed three themes to represent participants' narratives: PICU cases and context as dynamic affordances; impact of psychological safety; and the role of attending physicians. While Thai PICU cases and context could afford participation and thus learning, Thailand's collectivist culture, which prioritises group needs over individual needs, contributed to a sense of psychological safety within culturally-endorsed, professional and social hierarchies, and set the stage for workplace learning. Despite their higher status in these hierarchies, attending physicians facilitated resident learning by fostering open dialogue, joint problem-solving and a low-stress atmosphere. CONCLUSIONS: Workplace learning in a Thai PICU while challenging, is uniquely facilitated by Thailand's collectivist culture that fosters psychological safety and attending physicians' invitation in, and learn from, the workplace optimises learning.

How Might we Build an Equitable Future? Design Justice, a Counternarrative to Dominant Approaches in Medical Education.

PHENOMENON: Marginalized individuals in medicine face many structural inequities which can have enduring consequences on their progress. Therefore, inequity must be addressed by dismantling underlying unjust policies, environments, and curricula. However, once these injustices have been taken apart, how do we build more just systems from the rubble? Many current strategies to address this question have foundational values of urgency, solutionism, and top-down leadership. APPROACH: This paper explores a counternarrative: Design Justice. As a set of guiding principles, Design Justice centers the experiences and perspectives of marginalized individuals and communities. These principles include mutual accountability and transparency, co-ownership, and community-led outcomes, and honoring local, traditional, Indigenous knowledge. FINDINGS: Rooted in critical scholarship and critical design, Design Justice recognizes the interconnectedness of various forms of marginalization and works to critically examine power dynamics that exist in every design process. These co-created principles act as practical guardrails, directing progress toward justice. INSIGHTS: This paper begins with an overview of Design Justice's history in critical scholarship and critical design, providing foundational background knowledge for medical educators, scholars, and leaders in key concepts of justice and design. We explore how the Design Justice principles were developed and have been applied across sectors, highlighting its applications, including education applications. Finally, we raise critical questions about medical education prompted by Design Justice.

Clarifying and expanding equity in assessment by considering three orientations: Fairness, inclusion and justice.

CONTEXT: Despite increasing discussion and scholarship, equity in assessment is rarely defined and distinguished in a way that allows for shared understanding in medical education. This paper seeks to clarify and expand the conversation about equity in assessment by critically reviewing three distinct and evolving orientations toward equity in assessment. Orientations refers to the positions, attitudes, interests or priorities individuals can hold toward equity in assessment. The three orientations include fairness-oriented assessment, assessment for inclusion and justice-oriented assessment. While fairness-oriented assessment is a prevailing orientation in medical education, assessment for inclusion and justice-oriented assessment, originally developed in other fields of education, deserve careful consideration. METHODS: In this paper, the authors explore unique underpinning assumptions of each orientation by critically examining the foundational literature of each orientation. They reflect on the unique perspectives each orientation provides, including the actions one might take and what advantages and disadvantages might result from looking at equity in assessment from any one orientation. CONCLUSIONS: Informed by this reflection, the authors propose that to more effectively advance equity in assessment in medical education, those working in the field should clearly identify their respective orientations, intentionally choose methods, tools and measures aligned with their orientations and expand their work by exploring alternative orientations.

Patients, Peers, and Personal Identity: A Longitudinal Qualitative Study Exploring the Transformative Potential of the Arts and Humanities in Intern Training.

PURPOSE: Medical education initiatives incorporate arts and humanities (AHs) to foster physician competence and professionalism. However, the full potential of these initiatives is unclear. A recent conceptual framework attempts to clarify this potential but was constructed primarily from undergraduate medical education studies. To explore AH instruction in graduate medical education (GME), the authors asked: What is the potential of a longitudinal curriculum incorporating AHs for the personal and professional development of internal medicine interns throughout the intern year? METHOD: From September 2021 to June 2022, 14 internal medicine interns at a large internal medical residency program participated in a longitudinal qualitative study, recording longitudinal audio-diaries (LADs) and participating in semistructured interviews. The LAD response rate was 91%, and the interview completion rate was 96%. The authors identified 3 themes that reflected shared meaning on the transformative potential of AHs: reclaiming personal sense of self, building community, and surfacing empathy. They constructed stories from 2 interns whose trajectories resonated most with AH instruction's potential for personal and professional development. RESULTS: Interns valued the abstract over the concrete benefits of AHs. Interns detailed valuable abstract benefits, with reclaiming sense of self, building community, and surfacing empathy apparent across time, pointing to long-term effects of AH interventions. The intern stories revealed a steady appreciation for AHs and difficulty with the practical utility of AHs midyear before a return to recognition of its value by year's end. CONCLUSIONS: Despite varying AHs experience levels, interns consistently appreciated AH instruction. These findings extend a prior conceptual model to a GME population by highlighting AH instruction's potential for reclaiming interns' senses of self, building community, and surfacing empathy. Future curricula can leverage this ability to create meaningful connections with one's purpose, peers, and patients to maximize the potential of AH instruction for GME learners.

Using a longitudinal qualitative approach to understand the lived experiences of caregivers of infants with obstructive sleep apnea who require chronic noninvasive respiratory support.

OBJECTIVE: Although positive airway pressure (PAP) is effective for treating obstructive sleep apnea (OSA) in infants, there is a lack of data on caregivers' experiences administering PAP at home. Understanding caregivers' perspectives may change health care professionals approach to PAP initiation. Our study aimed to gain comprehensive insight into caregivers' beliefs, perceptions, and challenges associated with implementing PAP for infants with OSA, considering the transition from inpatient hospitalization to home. METHODS: In this single-center prospective longitudinal study, caregivers of infants with OSA less than 12 months old who were initiated PAP during inpatient hospitalization underwent two semi-structured interviews over 3 months. The interview data were analyzed using directed content analysis, utilizing the health belief and socioecological models as theoretical frameworks. Data were coded and clustered into themes that reflected the evolving perspectives and experiences of caregivers. RESULTS: Eight caregivers completed semi-structured interviews, revealing three key themes. First, despite initial negative attitudes towards the equipment, caregivers recognized PAP benefits and through self-efficacy and cues to action, were motivated to use PAP at home. Second, caregivers encountered various barriers to adherence; however, caregivers' self-efficacy improved with time and practice. Lastly, interpersonal, organizational, and community support enhanced adherence while lack thereof hindered implementation. CONCLUSION: Caregivers of infants with OSA understand the importance of PAP therapy. Providing family-centered care and targeted interventions helps caregivers maintain adherence to PAP for infants. By understanding the lived experiences of caregivers, health care professionals can better meet the needs of families and optimize the effectiveness of PAP.

"Making Space for More People, More Perspectives, and More Ideas": How Medical Education Journal Editors View Their Role in Capacity Building.

PURPOSE: Medical education journal editors work to improve scholarly rigor and expand access to scholarship. How editors conceptualize these dual roles is unknown and holds implications for the kinds of scholarship that are valued and made visible through publication. The authors applied the concept of capacity building to examine how medical education journal editors conceptualize and operationalize capacity building and to identify the contextual factors that support or constrain these efforts. METHOD: Using a reflexive thematic approach, the authors interviewed 13 editors of 11 medical education journals between February 2022 and March 2023. Data collection and analyses were performed iteratively. Interview transcripts were coded by 2 authors to generate initial codes, which were then refined by the research team until final themes were created. RESULTS: Editors viewed capacity building "making space" for people and perspectives. Making space for people included efforts to support editors and reviewers, offer feedback to authors, and engage with readers. Making space for perspectives included efforts to promote discussion on diversity and inclusion and to introduce ideas perceived to advance the field. How editors made space was shaped by a journal's ecosystem, including local features unique to each journal (e.g., aims, scope, readership) and system-level factors that influenced all journals (e.g., English as the language of science, academic promotion and tenure). CONCLUSIONS: Although medical education journal editors' capacity-building work will inevitably guide future scholars and scholarship, their work should be considered in the context of a larger ecosystem, including such features as institutional academies for scholarship and promotion and tenure policies. Improving rigor and expanding access will require clarifying how editors' approach and understand capacity building to advance as a field. Future work should clarify how individual journals' capacity-building efforts can be facilitated and how journals can collectively reimagine spaces for knowledge-building conversations.

Pediatric Hospital Medicine Fellows' Perspectives on Autonomy Through Time.

OBJECTIVE: Promoting autonomy is at the core of fellowship education. Pediatric hospital medicine (PHM) fellowship programs are relatively new, and many supervising physicians are not trained on how to promote fellow autonomy. Moreover, no studies have explored fellows' perception of autonomy throughout training. To fill this gap, we explored PHM fellows' perceptions of autonomy throughout training. METHODS: PHM fellows starting fellowship in July 2021 were recruited to participate in a longitudinal qualitative study. Using self-determination theory as a sensitizing framework, the authors conducted semistructured interviews with 14 fellows throughout fellowship. Incoming data were iteratively analyzed, and codes were created from patterns in the data. Coded data were clustered into themes. RESULTS: Four themes developed: (1) at the beginning of fellowship, fellows valued direct observation and close supervision from their attending. (2) Initially, fellows felt pressured to make the identical clinical decision as their attending, but over the course of training, they realized their autonomous decisions could coexist with different decisions from their attending physicians. (3) At first, fellows desired attending presence to support and guide their decision making. Over time, fellows desired a coach who could provide valuable formative feedback. (4) Because of the hierarchical nature of medicine, conversations between fellows and attending physicians about autonomy were challenging to initiate. CONCLUSIONS: Fellows' perceptions of autonomy change throughout fellowship, which should be taken into consideration as provisions of autonomy evolve through training. Our findings can inform PHM fellowship curricula and professional development around the promotion of autonomy in fellowship.

Physicians' lifelong learning journeys: A narrative analysis of continuing professional development struggles.

INTRODUCTION: Despite tenacious efforts of continuing professional development (CPD) developers and educators, physician engagement in CPD is fraught with challenges. Research suggests that these educational interventions and the maintenance of professional competence systems that mandate them are often seen as impractical, decontextualized and check-box activities by participants. This study explores physicians' learning post graduate medical education (GME) training across their CPD journey to understand how they (a) conceive of themselves as learners and (b) engage in lifelong learning across the course of their professional careers. METHODS: Using narrative inquiry and holistic narrative analysis situated within a social constructivist orientation, we carried out individual interviews with physicians from across a large children's hospital network including academic hospitals, community hospitals and primary care practices. Timelines and story arcs were used to support the narrative analysis's re-storying. RESULTS: Twelve physicians from six different sub-specialties were interviewed. We identified three noteworthy challenges as particularly salient across participants' re-storied narratives: (i) train-on-a-track to treading water, (ii) learning takes a backseat, and (iii) learning through foraging or hunting and gathering. Participants described significant change when transitioning from GME to CPD learning. While participants identified as learners, they described the disorienting impact of losing GME's formal supports and structures. They articulated that patient care trumped learning as their top priority. They lamented having limited insight into their learning needs (e.g. little feedback data) and so resorted to engaging in CPD activities that were readily at hand-but not necessarily relevant-and to finding learning resources that might not be formally recognised for CPD credit. CONCLUSIONS: Physicians' learning journeys post-GME are challenging, and the systems created to support that learning are ill equipped to meet the needs of physicians transitioning from GME to CPD. To encourage meaningful learning, the complex interplay of factors impeding CPD engagement should inform future innovations.

Counternarratives that illuminate faculty agency: A five-year longitudinal qualitative study of physician educators in academic medicine.

PURPOSE: Physician educators are often expected to direct educational programs and assume roles that conform to field norms for career advancement but that may not afford meaningful work for educators. The purpose of this study was to describe and analyse the perspectives and actions taken by physician educators in response to tension between feeling compelled to direct an educational program and doing educationally meaningful work. METHODS AND MATERIALS: We used data from a longitudinal study and focused on three participants who, over the course of the five-year study, offered significant insights into how physician educators act in ways that run counter to expectations for career advancement. Our narrative analysis entailed organizing data from interview transcripts into time-ordered displays, weaving data into counternarratives that were edited by participants, and using the theory of faculty agency (and its key constructs, strategic perspectives and strategic action) to thread the stories together. RESULTS: In each counternarrative, the participant deliberated their sense of being a physician educator (strategic perspectives) and when expectations became untenable, they did what they needed to do to engage in meaningful work (strategic action) rather than comply with expectations for career advancement in academic medicine. For one participant, faculty agency meant leaving academic medicine; for another, it meant reducing clinical time so that unpaid time could be devoted to education; and for another, it meant opting not do direct a reputable education program. CONCLUSIONS: Faculty agency is a useful theoretical lens for conceptualizing how physician educators navigate their careers in academic medicine. Counternarratives that illuminate faculty agency offer stories that describe alternate career paths and portend a different future for physician educators.

What Do You See? Signature Pedagogy in Continuous Electroencephalography Teaching.

PURPOSE: Electroencephalography (EEG) is commonly used in neurology, but there is variability in how neurologists interpret EEGs, potentially from variability in EEG teaching. Little is known about how EEG teaching is done to prepare neurologists for professional practice. METHODS: We interviewed a group of EEG experts to characterize their teaching practices around continuous EEG (cEEG). We used signature pedagogy as a framework to analyze and interpret the data. RESULTS: We identified pervasive and characteristic forms of cEEG teaching. Teaching is based on apprenticeship, relying on "learning by doing" in the context of real-life clinical practice. There are habitual steps that learners take to anchor teaching, which typically occurs during rounds. There is a common language and core knowledge that trainees need to master early in their training. CONCLUSIONS: There are pervasive characteristic forms of cEEG teaching. These findings can help facilitate instructional design and implementation of complementary or enhanced cEEG teaching practices.

Lifelong Learning Indicators in Medical Students After a Novel Communication Skills Session.

CONTEXT: A growth mindset and mastery approach have gained attention as useful learning orientations in medical education, however few studies of interventions to foster these orientations exist. OBJECTIVES: We sought to discover whether a communication skills session on delivering serious news could foster a communication growth mindset and/or a mastery approach in medical students. METHODS: This was an interventional survey study of third-year medical students before and after a session on delivering serious news. Students were administered a communication mindset survey before and after the session; achievement goal and learning environment surveys were administered after the session. Chi-square tests were used to assess the difference in pre and post mindsets. Logistic regression was used to determine the odds of achieving a mastery approach with pre- and post-communication growth mindset as the independent variables. RESULTS: Students' communication growth mindset increased from 79% (n = 186) before the intervention to 92% (n = 142) after the intervention. Achievement goal analysis demonstrated that 64% (n = 91) of students had a mastery approach, 14% (n = 20) had a performance approach and 22% (n = 32) had an avoidant approach. Ninety-nine percent (n = 151) felt the session provided a safe learning environment. The odds of having a mastery approach correlated with both pre and post-intervention growth mindset, with post-session growth mindset having the strongest correlation. CONCLUSIONS: A novel communication skills session on delivering serious news fostered a communication growth mindset in third year medical students. Most students exhibited a mastery approach to learning; this approach was more likely when they had a growth mindset.

A Qualitative Exploration of Pediatric Resident Perceptions of Autonomy in the Era of Pediatric Hospital Medicine Fellowship.

OBJECTIVE: Some pediatric residents report experiencing less autonomy when working clinically with pediatric hospital medicine (PHM) fellows than with attendings alone. We sought to explore pediatric senior resident (SR) experiences working clinically with PHM fellows, with a focus on characterizing fellow behaviors that could impact perceived resident autonomy. METHODS: In this qualitative study, we conducted virtual semistructured interviews with pediatric SRs. We recorded, deidentified, and transcribed interviews for codebook thematic analysis, making iterative adjustments to our codebook and themes until reaching thematic sufficiency. RESULTS: We conducted 17 interviews. A subanalysis identified key components of the resident mental model of autonomy, including independent clinical decision-making with 3 core qualifiers: 1) plan follow-through, 2) availability of a safety net, and 3) ownership. Our primary analysis identified 4 key themes (with a total of 7 contributory subthemes) describing resident experiences of autonomy, scaffolded based on an organizing framework adapted from Bronfenbrenner's ecological model including 1) microsystem factors (based on direct resident-fellow or resident-leadership team interactions), 2) mesosystem factors (based on fellow-attending interactions), 3) exosystem factors (based on fellow-intrinsic characteristics), and 4) macrosystem factors (cultural values, norms, and policies governing academic pediatrics). CONCLUSIONS: Many factors impact perceived resident autonomy on PHM fellow-inclusive teams. Although some are related to direct resident-fellow interactions, many others are more complex and may reflect resident interactions with the leadership team, attending-fellow dynamics, and the influence of cultural context. Based on our analysis, we propose several best-practice recommendations directed at fellows, attendings, the fellow-attending dyad, and Graduate Medical Education programs overall.

Evaluation of a Palliative Care Longitudinal Curriculum for Medical Students Using the Context-Input-Process-Product Model.

Palliative care (PC) longitudinal curricula are increasingly being recognized as important in Undergraduate Medical Education (UME). They are however, not yet commonplace, and where they do exist may be implemented without a systematic, prospective approach to curriculum evaluation. This paper describes an implementation of a new longitudinal curriculum at the Perelman School of Medicine (PSOM) at the University of Pennsylvania. We used the Context Input Process Product (CIPP) model, a holistic evaluation model, to assess the local environment, design the curriculum, guide the improvement process, and evaluate outcomes. Comprehensive models such as CIPP provide a more robust approach to curriculum evaluation than outcomes-only models and may be of use to other programs who are implementing new curricula or improving upon existing programs.

Inequity is woven into the fabric: a discourse analysis of assessment in pediatric residency training.

Intrinsic inequity in assessment refers to sources of harmful discrimination inherent in the design of assessment tools and systems. This study seeks to understand intrinsic inequity in assessment systems by studying assessment policies and associated procedures in residency training, using general pediatrics as a discourse case study. Foucauldian discourse analysis (FDA) was conducted on assessment policy and procedure documents. Two authors independently prepared structured analytic notes using guiding questions. Documents and respective analytic notes were subsequently reviewed independently by all authors. Each author prepared further unstructured analytic notes on the documents' discourse. The authors then compared notes and constructed truth statements (i.e., interpretations of what the discourse establishes as true about the construct under study) and sub-strands (i.e., themes) that were repeated and legitimized across the documents via iterative discussion. Based on analysis, the authors constructed two truth statements. These truth statements, "good assessment is equitable assessment," and "everyone is responsible for inequity," conceptualized inequity in assessment as an isolated or individual-level aberration in an otherwise effective or neutral system. Closer examination of the truth statements and sub-strands in the discourse presented an alternative view, suggesting that inequity may in fact not be an aberration but rather an inherent feature of assessment systems.