Human atherosclerotic plaque transcriptomics reveals endothelial beta-2 spectrin as a potential regulator a leaky plaque microvasculature phenotype.

The presence of atherosclerotic plaque vessels is a critical factor in plaque destabilization. This may be attributable to the leaky phenotype of these microvessels, although direct proof for this notion is lacking. In this study, we investigated molecular and cellular patterns of stable and hemorrhaged human plaque to identify novel drivers of intraplaque vessel dysfunction. From transcriptome data of a human atherosclerotic lesion cohort, we reconstructed a co-expression network, identifying a gene module strongly and selectively correlated with both plaque microvascular density and inflammation. Spectrin Beta Non-Erythrocytic 1 (sptbn1) was identified as one of the central hubs of this module (along with zeb1 and dock1) and was selected for further study based on its predominant endothelial expression. Silencing of sptbn1 enhanced leukocyte transmigration and vascular permeability in vitro, characterized by an increased number of focal adhesions and reduced junctional VE-cadherin. In vivo, sptbn1 knockdown in zebrafish impaired the development of the caudal vein plexus. Mechanistically, increased substrate stiffness was associated with sptbn1 downregulation in endothelial cells in vitro and in human vessels. Plaque SPTBN1 mRNA and protein expression were found to correlate with an enhanced presence of intraplaque hemorrhage and future cardiovascular disease (CVD) events during follow-up. In conclusion, we identify SPTBN1 as a central hub gene in a gene program correlating with plaque vascularisation. SPTBN1 was regulated by substrate stiffness in vitro while silencing blocked vascular development in vivo, and compromised barrier function in vitro. Together, SPTBN1 is identified as a new potential regulator of the leaky phenotype of atherosclerotic plaque microvessels.

Designing feedback processes in the workplace-based learning of undergraduate health professions education: a scoping review.

BACKGROUND: Feedback processes are crucial for learning, guiding improvement, and enhancing performance. In workplace-based learning settings, diverse teaching and assessment activities are advocated to be designed and implemented, generating feedback that students use, with proper guidance, to close the gap between current and desired performance levels. Since productive feedback processes rely on observed information regarding a student's performance, it is imperative to establish structured feedback activities within undergraduate workplace-based learning settings. However, these settings are characterized by their unpredictable nature, which can either promote learning or present challenges in offering structured learning opportunities for students. This scoping review maps literature on how feedback processes are organised in undergraduate clinical workplace-based learning settings, providing insight into the design and use of feedback. METHODS: A scoping review was conducted. Studies were identified from seven databases and ten relevant journals in medical education. The screening process was performed independently in duplicate with the support of the StArt program. Data were organized in a data chart and analyzed using thematic analysis. The feedback loop with a sociocultural perspective was used as a theoretical framework. RESULTS: The search yielded 4,877 papers, and 61 were included in the review. Two themes were identified in the qualitative analysis: (1) The organization of the feedback processes in workplace-based learning settings, and (2) Sociocultural factors influencing the organization of feedback processes. The literature describes multiple teaching and assessment activities that generate feedback information. Most papers described experiences and perceptions of diverse teaching and assessment feedback activities. Few studies described how feedback processes improve performance. Sociocultural factors such as establishing a feedback culture, enabling stable and trustworthy relationships, and enhancing student feedback agency are crucial for productive feedback processes. CONCLUSIONS: This review identified concrete ideas regarding how feedback could be organized within the clinical workplace to promote feedback processes. The feedback encounter should be organized to allow follow-up of the feedback, i.e., working on required learning and performance goals at the next occasion. The educational programs should design feedback processes by appropriately planning subsequent tasks and activities. More insight is needed in designing a full-loop feedback process, in which specific attention is needed in effective feedforward practices.

An exploratory university-based cross-sectional study of the prevalence and reporting of mistreatment and student-related factors among Thai medical students.

BACKGROUND: Mistreatment is a behavior that reflects disrespect for the dignity of others. Mistreatment can be intentional or unintentional, and can interfere with the process of learning and perceived well-being. This study explored the prevalence and characteristics of mistreatment, mistreatment reporting, student-related factors, and consequences among medical students in Thai context. METHODS: We first developed a Thai version of the Clinical Workplace Learning Negative Acts Questionnaire-Revised (NAQ-R) using a forward-back translation process with quality analysis. The design was a cross-sectional survey study, using the Thai Clinical Workplace Learning NAQ-R, Thai Maslach Burnout Inventory-Student Survey, Thai Patient Health Questionnaire (to assess depression risk), demographic information, mistreatment characteristics, mistreatment reports, related factors, and consequences. Descriptive and correlational analyses using multivariate analysis of variance were conducted. RESULTS: In total, 681 medical students (52.4% female, 54.6% in the clinical years) completed the surveys (79.1% response rate). The reliability of the Thai Clinical Workplace Learning NAQ-R was high (Cronbach's alpha 0.922), with a high degree of agreement (83.9%). Most participants (n = 510, 74.5%) reported that they had experienced mistreatment. The most common type of mistreatment was workplace learning-related bullying (67.7%), and the most common source was attending staff or teachers (31.6%). People who mistreated preclinical medical students were most often senior students or peers (25.9%). People who mistreated clinical students were most commonly attending staff (57.5%). Only 56 students (8.2%) reported these instances of mistreatment to others. Students' academic year was significantly related to workplace learning-related bullying (r = 0.261, p < 0.001). Depression and burnout risk were significantly associated with person-related bullying (depression: r = 0.20, p < 0.001, burnout: r = 0.20, p = 0.012). Students who experienced person-related bullying were more often the subject of filed unprofessional behavior reports, concerning conflict or arguments with colleagues, being absent from class or work without reasonable cause, and mistreatment of others. CONCLUSIONS: Mistreatment of medical students was evident in medical school and was related to the risk for depression and burnout, as well as the risk of unprofessional behavior. TRIAL REGISTRATION: TCTR20230107006(07/01/2023).

An international study on the implementation of programmatic assessment: Understanding challenges and exploring solutions.

INTRODUCTION: Programmatic assessment is an approach to assessment aimed at optimizing the learning and decision function of assessment. It involves a set of key principles and ground rules that are important for its design and implementation. However, despite its intuitive appeal, its implementation remains a challenge. The purpose of this paper is to gain a better understanding of the factors that affect the implementation process of programmatic assessment and how specific implementation challenges are managed across different programs. METHODS: An explanatory multiple case (collective) approach was used for this study. We identified 6 medical programs that had implemented programmatic assessment with variation regarding health profession disciplines, level of education and geographic location. We conducted interviews with a key faculty member from each of the programs and analyzed the data using inductive thematic analysis. RESULTS: We identified two major factors in managing the challenges and complexity of the implementation process: knowledge brokers and a strategic opportunistic approach. Knowledge brokers were the people who drove and designed the implementation process acting by translating evidence into practice allowing for real-time management of the complex processes of implementation. These knowledge brokers used a 'strategic opportunistic' or agile approach to recognize new opportunities, secure leadership support, adapt to the context and take advantage of the unexpected. Engaging in an overall curriculum reform process was a critical factor for a successful implementation of programmatic assessment. DISCUSSION: The study contributes to the understanding of the intricacies of implementation processes of programmatic assessment across different institutions. Managing opportunities, adaptive planning, awareness of context, were all critical aspects of thinking strategically and opportunistically in the implementation of programmatic assessment. Future research is needed to provide a more in-depth understanding of values and beliefs that underpin the assessment culture of an organization, and how such values may affect implementation.

Promoting a sense of belonging, engagement, and collegiality to reduce burnout: a mixed methods study among undergraduate medical students in a non-Western, Asian context.

BACKGROUND: Burnout is a psychological condition induced by work-related chronic interpersonal stressors. Interventions creating a sense of belonging and collegiality have been proposed as approaches for alleviating burnout. The current study aimed to: (1) explore the relationships between burnout, sense of belonging (relatedness with others), and work engagement; and (2) identify the key elements perceived by undergraduate medical students as positively contributing to collegiality, engagement, and a sense of belonging, in an undergraduate medical training setting. METHODS: An exploratory sequential mixed-methods design using questionnaires and semi-structured individual interviews collected quantitative and qualitative data among undergraduate medical students at Mahidol University, Thailand. The Maslach Burnout Inventory-Student Survey questionnaire was used to measure burnout. The Basic Psychological Need Satisfaction at Work Scale (BPNSS-21) and the Utrecht Work Engagement Scale-Student Version (UWESS-9) measured students' basic psychological needs satisfaction at work and work engagement, respectively. Descriptive statistical analysis and confirmatory factor analysis were performed on BPNSS-21 and UWESS-9 data. Spearman's correlation coefficient was used to identify the correlation between burnout and other factors. Twenty undergraduate medical students participated in the qualitative study. Qualitative analysis was conducted iteratively using constant comparison and the standard principles of primary, secondary, and tertiary coding for thematic analysis. RESULTS: Thai versions of the BPNSS-21 and UWESS-9 showed an acceptable fit for the Thai cultural context. Burnout had significant weak inverse associations with engagement (r = - 0.39, p < 0.005) and basic psychological needs satisfaction (r = - 0.37, p < 0.005). Sense of belonging had a significant weak inverse relationship with burnout (r = - 0.25, p < 0.005). The main themes emerging from qualitative analysis were relevant tasks and learning activities, safety in the learning environment, peer interaction, program design factors, dynamics of collegiality while progressing through medical school, and personal stance and social skills. CONCLUSIONS: Sense of belonging, engagement, and collegiality were related to burnout. The key features for promoting collegiality, the sense of belonging, and engagement were relevant tasks and learning activities, safety in the learning environment, peer interaction, program design factors, dynamics of collegiality while progressing through medical school, and personal stance and social skills.

Designing a system for performance appraisal: balancing physicians' accountability and professional development.

BACKGROUND: In many healthcare systems, physicians are accustomed to periodically participate in individual performance appraisals to guide their professional development. For the purpose of revalidation, or maintenance of certification, they need to demonstrate that they have engaged with the outcomes of these appraisals. The combination of taking ownership in professional development and meeting accountability requirements may cause undesirable interference of purposes. To support physicians in their professional development, new Dutch legislation requires that they discuss their performance data with a non-hierarchical (peer)coach and draft a personal development plan. In this study, we report on the design of this system for performance appraisal in a Dutch academic medical center. METHODS: Using a design-based research approach, a hospital-based research group had the lead in drafting and implementing a performance appraisal protocol, selecting a multisource feedback tool, co-developing and piloting a coaching approach, implementing a planning tool, recruiting peer coaches and facilitating their training and peer group debriefings. RESULTS: The system consisted of a two-hour peer-to-peer conversation based on the principles of appreciative inquiry and solution-focused coaching. Sessions were rated as highly motivating, development-oriented, concrete and valuable. Peer coaches were considered suitable, although occasionally physicians preferred a professional coach because of their expertise. The system honored both accountability and professional development purposes. By integrating the performance appraisal system with an already existing internal performance system, physicians were enabled to openly and safely discuss their professional development with a peer, while also being supported by their superior in their self-defined developmental goals. Although the peer-to-peer conversation was mandatory and participation in the process was documented, it was up to the physician whether or not to share its results with others, including their superior. CONCLUSIONS: In the context of mandatory revalidation, professional development can be supported when the appraisal process involves three characteristics: the appraisal process is appreciative and explores developmental opportunities; coaches are trustworthy and skilled; and the physician has control over the disclosure of the appraisal output. Although the peer-to-peer conversations were positively evaluated, the effects on physicians' professional development have yet to be investigated in longitudinal research designs.

Can concept mapping support the quality of reflections made by undergraduate medical students? A mixed method study.

BACKGROUND: Students perceive reflective writing as difficult. Concept mapping may be an alternative format for reflection, which provides support while allowing students to freely shape their thoughts. We examined (1) the quality of reflection in reflective concept maps created by first-year medical students and (2) students' perceptions about concept mapping as a tool for reflection. METHODS: Mixed-method study conducted within the medical curriculum of Maastricht University, The Netherlands, consisting of: (1) Analysis of the quality of reflection in 245 reflective concept maps created by 40 first-year students. Reflection quality was analysed by assessing focus of reflection (technical/practical/sensitising) and depth of reflection (description/justification/critique/discussion). (2) Semi-structured interviews with 22 students to explore perceived effectiveness of reflective concept mapping. RESULTS: Depth of reflection reached at least the level of critique in 82% of maps. Three factors appeared to affect the perceived effectiveness of concept mapping for reflection: (1) reflective concept map structure; (2) alertness to meaningful experiences in practice and (3) learning by doing. CONCLUSION: These results yielded supportive evidence for concept mapping as a useful technique to teach novice learners the basics of effective reflection. Meaningful implementation requires a delicate balance between providing a supportive structure and allowing flexibility for the student.

Ottawa 2020 consensus statement for programmatic assessment - 1. Agreement on the principles.

INTRODUCTION: In the Ottawa 2018 Consensus framework for good assessment, a set of criteria was presented for systems of assessment. Currently, programmatic assessment is being established in an increasing number of programmes. In this Ottawa 2020 consensus statement for programmatic assessment insights from practice and research are used to define the principles of programmatic assessment. METHODS: For fifteen programmes in health professions education affiliated with members of an expert group (n = 20), an inventory was completed for the perceived components, rationale, and importance of a programmatic assessment design. Input from attendees of a programmatic assessment workshop and symposium at the 2020 Ottawa conference was included. The outcome is discussed in concurrence with current theory and research. RESULTS AND DISCUSSION: Twelve principles are presented that are considered as important and recognisable facets of programmatic assessment. Overall these principles were used in the curriculum and assessment design, albeit with a range of approaches and rigor, suggesting that programmatic assessment is an achievable education and assessment model, embedded both in practice and research. Knowledge on and sharing how programmatic assessment is being operationalized may help support educators charting their own implementation journey of programmatic assessment in their respective programmes.

Ottawa 2020 consensus statements for programmatic assessment - 2. Implementation and practice.

INTRODUCTION: Programmatic assessment is a longitudinal, developmental approach that fosters and harnesses the learning function of assessment. Yet the implementation, a critical step to translate theory into practice, can be challenging. As part of the Ottawa 2020 consensus statement on programmatic assessment, we sought to provide descriptions of the implementation of the 12 principles of programmatic assessment and to gain insight into enablers and barriers across different institutions and contexts. METHODS: After the 2020 Ottawa conference, we surveyed 15 Health Profession Education programmes from six different countries about the implementation of the 12 principles of programmatic assessment. Survey responses were analysed using a deductive thematic analysis. RESULTS AND DISCUSSION: A wide range of implementations were reported although the principles remained, for the most part, faithful to the original enunciation and rationale. Enablers included strong leadership support, ongoing faculty development, providing students with clear expectations about assessment, simultaneous curriculum renewal and organisational commitment to change. Most barriers were related to the need for a paradigm shift in the culture of assessment. Descriptions of implementations in relation to the theoretical principles, across multiple educational contexts, coupled with explanations of enablers and barriers, provided new insights and a clearer understanding of the strategic and operational considerations in the implementation of programmatic assessment. Future research is needed to further explore how contextual and cultural factors affect implementation.

Extending the use of the conceptions of learning and teaching (COLT) instrument to the postgraduate setting.

BACKGROUND: Several studies have shown that conceptions of teachers on teaching and learning can influence the teaching practices and behavior in higher education. This association is also found in undergraduate medical education but not yet established in postgraduate medical setting. An instrument, Conceptions of Learning and Teaching (COLT) was developed to measure conception of teachers in undergraduate medical education. COLT is a 3-factor 18-item questionnaire. The objective of this study is to evaluate if COLT is valid for postgraduate medical education. METHODS: We invited postgraduate clinical faculty from 3 hospitals in the Netherlands to fill out the COLT. Confirmatory and exploratory factor analysis were performed to evaluate the fit of the postgraduate clinical faculty data to the COLT. Analysis of variance was done to evaluate if there was difference among the 3 hospitals in terms of the response by the clinical faculty. RESULTS: Confirmatory factor analysis showed that the postgraduate faculty data had a 2 factor structure after removal of five items. These factors were Teacher Centeredness (TC) and combined Appreciation of Active Learning and Orientation to Professional Practice (A-P) and were considered as comparable to the factors in the original COLT, expressing the post-graduate learning and teaching setting. As several items were removed, the fit was suboptimal, yet did suggest validity for use of the COLT for postgraduate medical education. CONCLUSION: The modified COLT can be used to measure conceptions of teaching and learning in postgraduate medical education. We recommend further study to improve the factor structure of the modified COLT.

Between trust and control: Teachers' assessment conceptualisations within programmatic assessment.

OBJECTIVES: Programmatic assessment attempts to facilitate learning through individual assessments designed to be of low-stakes and used only for high-stake decisions when aggregated. In practice, low-stake assessments have yet to reach their potential as catalysts for learning. We explored how teachers conceptualise assessments within programmatic assessment and how they engage with learners in assessment relationships. METHODS: We used a constructivist grounded theory approach to explore teachers' assessment conceptualisations and assessment relationships in the context of programmatic assessment. We conducted 23 semi-structured interviews at two different graduate-entry medical training programmes following a purposeful sampling approach. Data collection and analysis were conducted iteratively until we reached theoretical sufficiency. We identified themes using a process of constant comparison. RESULTS: Results showed that teachers conceptualise low-stake assessments in three different ways: to stimulate and facilitate learning; to prepare learners for the next step, and to use as feedback to gauge the teacher's own effectiveness. Teachers intended to engage in and preserve safe, yet professional and productive working relationships with learners to enable assessment for learning when securing high-quality performance and achievement of standards. When teachers' assessment conceptualisations were more focused on accounting conceptions, this risked creating tension in the teacher-learner assessment relationship. Teachers struggled between taking control and allowing learners' independence. CONCLUSIONS: Teachers believe programmatic assessment can have a positive impact on both teaching and student learning. However, teachers' conceptualisations of low-stake assessments are not focused solely on learning and also involve stakes for teachers. Sampling across different assessments and the introduction of progress committees were identified as important design features to support teachers and preserve the benefits of prolonged engagement in assessment relationships. These insights contribute to the design of effective implementations of programmatic assessment within the medical education context.

Understanding the influence of teacher-learner relationships on learners' assessment perception.

Low-stakes assessments are theorised to stimulate and support self-regulated learning. They are feedback-, not decision-oriented, and should hold little consequences to a learner based on their performance. The use of low-stakes assessment as a learning opportunity requires an environment in which continuous improvement is encouraged. This may be hindered by learners' perceptions of assessment as high-stakes. Teachers play a key role in learners' assessment perceptions. By investigating assessment perceptions through an interpersonal theory-based perspective of teacher-learner relationships, we aim to better understand the mechanisms explaining the relationship between assessment and learning within medical education. First, twenty-six purposefully selected learners, ranging from undergraduates to postgraduates in five different settings of programmatic assessment, were interviewed about their assessment task perception. Next, we conducted a focussed analysis using sensitising concepts from interpersonal theory to elucidate the influence of the teacher-learner relationship on learners' assessment perceptions. The study showed a strong relation between learners' perceptions of the teacher-learner relationship and their assessment task perception. Two important sources for the perception of teachers' agency emerged from the data: positional agency and expert agency. Together with teacher's communion level, both types of teachers' agency are important for understanding learners' assessment perceptions. High levels of teacher communion had a positive impact on the perception of assessment for learning, in particular in relations in which teachers' agency was less dominantly exercised. When teachers exercised these sources of agency dominantly, learners felt inferior to their teachers, which could hinder the learning opportunity. To utilise the learning potential of low-stakes assessment, teachers are required to stimulate learner agency in safe and trusting assessment relationships, while carefully considering the influence of their own agency on learners' assessment perceptions. Interpersonal theory offers a useful lens for understanding assessment relationships. The Interpersonal Circumplex provides opportunities for faculty development that help teachers develop positive and productive relationships with learners in which the potential of low-stakes assessments for self-regulated learning is realised.

Microvasculature and intraplaque hemorrhage in atherosclerotic carotid lesions: a cardiovascular magnetic resonance imaging study.

BACKGROUND: The presence of intraplaque haemorrhage (IPH) has been related to plaque rupture, is associated with plaque progression, and predicts cerebrovascular events. However, the mechanisms leading to IPH are not fully understood. The dominant view is that IPH is caused by leakage of erythrocytes from immature microvessels. The aim of the present study was to investigate whether there is an association between atherosclerotic plaque microvasculature and presence of IPH in a relatively large prospective cohort study of patients with symptomatic carotid plaque. METHODS: One hundred and thirty-two symptomatic patients with ≥2 mm carotid plaque underwent cardiovascular magnetic resonance (CMR) of the symptomatic carotid plaque for detection of IPH and dynamic contrast-enhanced (DCE)-CMR for assessment of plaque microvasculature. Ktrans, an indicator of microvascular flow, density and leakiness, was estimated using pharmacokinetic modelling in the vessel wall and adventitia. Statistical analysis was performed using an independent samples T-test and binary logistic regression, correcting for clinical risk factors. RESULTS: A decreased vessel wall Ktrans was found for IPH positive patients (0.051 ± 0.011 min- 1 versus 0.058 ± 0.017 min- 1, p = 0.001). No significant difference in adventitial Ktrans was found in patients with and without IPH (0.057 ± 0.012 min- 1 and 0.057 ± 0.018 min- 1, respectively). Histological analysis in a subgroup of patients that underwent carotid endarterectomy demonstrated no significant difference in relative microvessel density between plaques without IPH (n = 8) and plaques with IPH (n = 15) (0.000333 ± 0.0000707 vs. and 0.000289 ± 0.0000439, p = 0.585). CONCLUSIONS: A reduced vessel wall Ktrans is found in the presence of IPH. Thus, we did not find a positive association between plaque microvasculature and IPH several weeks after a cerebrovascular event. Not only leaky plaque microvessels, but additional factors may contribute to IPH development. TRIAL REGISTRATION: NCT01208025 . Registration date September 23, 2010. Retrospectively registered (first inclusion September 21, 2010). NCT01709045 , date of registration October 17, 2012. Retrospectively registered (first inclusion August 23, 2011).

Development and initial validation of a dual-purpose questionnaire capturing mentors' and mentees' perceptions and expectations of the mentoring process.

BACKGROUND: In health profession education, learners are often coached by mentors for development of competencies, self-direction of learning and professionalism. It is important that the mentee-mentor relationship is aligned in terms of mutual expectations. METHODS: A dual-purpose questionnaire capturing both the mentor and mentee perceptions on the actual and preferred mentoring functions was designed and validated, by performing a principal component analysis (PCA) using the data of mentees (n = 103) and mentors (n = 23) of a medical course. As a proof of concept, alignment of needs and changes in the mentoring perceptions in mentee groups of different years were determined. RESULTS: PCA showed that specific sets of questions addressed important elements in the mentoring process, such as self-direction of learning and reflection (Scale 1), guidance of behavioural change (Scale 4), addressing personal issues and professional identity development (Scale 3 and 5) and how the mentor and mentee presents oneself in the mentoring relationship (Scale 2). Mentors and mentees perceived comparable situations as critical for an effective mentoring process, such as mentor presence and guidance of reflection, although there was also evidence of gaps, such as perception of cultural issues. By comparison of the mentee groups in the different years of the program, the dynamic or evolving nature of the mentor process became evident, mentees experienced more emphasis by the mentor on reflection (Scale 1), at a constant level of mentor presence (Scale 2). CONCLUSION: Given the individualized, context-specific, and dynamic nature of mentoring, programmes would benefit from a regular evaluation of mentoring practices, e.g. by using questionnaires, in order to facilitate organizational revisions and further development of the mentoring competencies.

Correction to: Exploring burnout and the association with the educational climate in pediatric residents in Thailand.

Following publication of the original article.

Exploring burnout and the association with the educational climate in pediatric residents in Thailand.

BACKGROUND: This study, undertaken in Bangkok, Thailand, explored the extent to which paediatric residents in a non-Western setting experienced burnout and the potential association with factors in the medical educational climate and work-related quality of life. METHODS: An exploratory sequential mixed methods design was employed in a cross-sectional study. The initial, quantitative phase used the validated Maslach Burnout Inventory, the Postgraduate Hospital Educational Environmental Measure (PHEEM) and Work-Related Quality of Life scale (WRQoL). Regression analysis was used to identify the correlation between burnout and educational climate. Thereafter, residents in all years with high levels of burnout on subscales were interviewed individually. RESULTS: Forty-one paediatric residents completed the three questionnaires. None had high levels related to burnout in all three domains (emotional exhaustion, high level of depersonalization and perceived low personal accomplishment), seven (17%) showed high levels in two out of three domains. Emotional exhaustion and educational climate (perceptions of role autonomy, perceptions of teaching, perceptions of social support) were correlated with work-related quality of life. In the interviews, the main themes related to burnout were inappropriate tasks, teachers and teaching styles, the perception of knowledge insecurity relating to task performance, time dimensions, life crisis during training, role expectations and work allocation clarity, and facilities such as accommodation. CONCLUSIONS: The study, in a non-Western setting, demonstrated a positive relation between educational climate and work-related quality of life. To help reduce the risk of burnout, the following factors were identified: minimize unnecessary or duplicated workload, schedule time arrangements to avoid extension of regular duty hours, and clearly define role expectations. The impact of inappropriate tasks, teachers and teaching styles (including unsafe environment) on the incidence of burnout was also highlighted. Additional studies focusing on teaching styles, safe learning climate and mistreatment in a non-Western context are needed.

Stakes in the eye of the beholder: an international study of learners' perceptions within programmatic assessment.

OBJECTIVES: Within programmatic assessment, the ambition is to simultaneously optimise the feedback and the decision-making function of assessment. In this approach, individual assessments are intended to be low stakes. In practice, however, learners often perceive assessments designed to be low stakes as high stakes. In this study, we explored how learners perceive assessment stakes within programmatic assessment and which factors influence these perceptions. METHODS: Twenty-six learners were interviewed from three different countries and five different programmes, ranging from undergraduate to postgraduate medical education. The interviews explored learners' experience with and perception of assessment stakes. An open and qualitative approach to data gathering and analyses inspired by the constructivist grounded theory approach was used to analyse the data and reveal underlying mechanisms influencing learners' perceptions. RESULTS: Learners' sense of control emerged from the analysis as key for understanding learners' perception of assessment stakes. Several design factors of the assessment programme provided or hindered learners' opportunities to exercise control over the assessment experience, mainly the opportunities to influence assessment outcomes, to collect evidence and to improve. Teacher-learner relationships that were characterised by learners' autonomy and in which learners feel safe were important for learners' believed ability to exercise control and to use assessment to support their learning. CONCLUSIONS: Knowledge of the factors that influence the perception of assessment stakes can help design effective assessment programmes in which assessment supports learning. Learners' opportunities for agency, a supportive programme structure and the role of the teacher are particularly powerful mechanisms to stimulate the learning value of programmatic assessment.

Reflection revisited: how physicians conceptualize and experience reflection in professional practice - a qualitative study.

BACKGROUND: For the purpose of continuous performance improvement, physicians are expected to reflect on their practice. While many reflection studies are theoretically oriented and often prescriptive in the sense that they conceptualize what reflection should look like, the current study starts with practicing physicians themselves and maps how these physicians conceptualize and experience reflection in daily professional practice. METHODS: We conducted a qualitative study using in-depth interviews with 13 hospital-based physicians from various specialties and institutions. The interviews were transcribed verbatim and were analyzed iteratively, following the interpretative phenomenological analysis approach. RESULTS: Data analysis resulted in the identification of three main topics: fuzziness, domain specificity and dialogical dynamics of reflection in professional practice. Reflection was conceptualized as a fuzzy process of contemplation and action, leading to change and hopefully improvement of personal performance and health care in general. Physicians' experiences with reflection were different for the patient domain and the team domain. Whereas experiences in the patient domain were recalled first and discussed in relatively clear terms, those in the team domain came second and were discussed in more ambiguous terms. In order to achieve improvement in daily practice, honest and open dialogues were perceived as necessary. These dialogues were regarded as the result of an interplay between an internal and an external dialogue. The internal dialogue required sensitivity and courage of the individual; the external dialogue required psychological safety and encouragement of the environment. Within the team domain however, handling the external dialogue effectively was not self-evident, underlining the importance of psychological safety. CONCLUSIONS: This study draws attention to the interdependence between the individual and the collective contributions to reflective activity in professional practice. Apart from its importance to physicians' individual medical performance, reflective activity is also important to the functioning of a team of physicians. To allow reflection to rise from an individual activity to a team activity, it is necessary to invest in a safe environment in which people are encouraged to think, act, and be engaged.

Cross-validation of a learning climate instrument in a non-western postgraduate clinical environment.

BACKGROUND: In postgraduate training, there is a need to continuously assess the learning and working conditions to optimize learning. Students or trainees respond to the learning climate as they perceive it. The Dutch Residency Educational Climate Test (D-RECT) is a learning climate measurement tool with well-substantiated validity. However, it was originally designed for Dutch postgraduate trainees and it remains to be shown whether extrapolation to non-Western settings is viable. The dual objective of this study was to revalidate D-RECT outside of a Western setting and to evaluate the factor structure of a recently revised version of the D-RECT containing 35 items. METHODS: We invited Filipino internal medicine residents from 96 hospitals to complete the revised 35-item D-RECT. Subsequently, we performed a confirmatory factor analysis to check the fit of the 9 scale model of the revised 35-item D-RECT. Inter-rater reliability was assessed using generalizability theory. RESULTS: Confirmatory factor analysis unveiled that the factor structure of the revised 35-item D-RECT provided a reasonable fit to the Filipino data, after removal of 7 items. Five to seven evaluations of individual residents were needed per scale to obtain a reliable result. CONCLUSION: Even in a non-Western setting, the D-RECT exhibited psychometric validity. This study validated the factor structure of the revised 35-item D-RECT after some modifications. We recommend that its application be extended to other Asian countries and specialties.

Vessel wall and adventitial DCE-MRI parameters demonstrate similar correlations with carotid plaque microvasculature on histology.

PURPOSE: To assess parameter agreement of volume transfer coefficient (Ktrans ) between two vascular regions and to study the correlation with microvessel density on histology. The dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameter Ktrans is frequently used to study atherosclerotic plaque microvasculature. Ktrans has been reported using different descriptive statistics (mean, median, 75th percentile) either for the whole vessel wall or the adventitia in previous studies. MATERIALS AND METHODS: DCE-MRI parameter agreement was analyzed in 110 symptomatic patients with ≥2 mm carotid plaque that underwent a 3T carotid DCE-MRI examination. Ktrans was estimated in the entire vessel wall and adventitia. Twenty-three patients underwent carotid endarterectomy and were used for comparison with histological quantification of microvessel density of the plaque using CD31 immunohistochemistry. DCE-MRI parameters in the vessel wall regions were compared using Pearson's correlation coefficient, Bland-Altman analysis, and a two-sided paired samples t-test. Correlation of the DCE-MRI parameters with histology was studied using the Pearson's correlation coefficient. RESULTS: Median adventitial Ktrans was 5% higher (P = 0.003) than entire vessel wall Ktrans , with no differences for other descriptive statistics. Vessel wall and adventitial Ktrans showed similar moderately strong correlations with plaque microvessel density on histology (Pearson's ρ: 0.59-0.65 [P < 0.003] and 0.52-0.64 [P < 0.011], respectively). CONCLUSION: The similar moderately strong correlations for vessel wall and adventitial Ktrans with microvessel density on histology suggested that both regions reflected plaque microvessel density. Care should to be taken when comparing absolute values between studies. Future studies incorporating thresholds for risk stratification need to agree upon standardization of DCE-MRI parameters. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1053-1059.