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.

Struggles and Joys: A Mixed Methods Study of the Artefacts and Reflections in Medical Student Portfolios.

Introduction: Portfolios scaffold reflection on experience so students can plan their learning. To elicit reflection, the learning experiences documented in portfolios must be meaningful. To understand what experiences first- and second-year medical students find meaningful, we studied the patterns in the artefacts chosen for portfolios and their associated written reflections. Methods: This explanatory mixed methods study of a longitudinal dataset of 835 artefacts from 37 medical student' portfolios, identified patterns in artefact types over time. Mixed model logistic regression analysis identified time, student and curriculum factors associated with inclusion of the most common types of artefacts. Thematic analysis of participants' reflections about their artefacts provided insight into their choices. Interpretation of the integrated findings was informed by Transformative Learning (TL) theory. Results: Artefact choices changed over time, influenced by curriculum changes and personal factors. In first year, the most common types of artefacts were Problem Based Learning mechanism diagrams and group photos representing classwork; in second year written assignments and 'selfies' representing social and clinical activities. Themes in the written reflections were Landmarks and Progress, Struggles and Strategies, Connection and Collaboration, and Joyful Memories for Balance. Coursework artefacts and photographic self-portraits represented all levels of transformative learning from across the curriculum. Conclusions: Medical students chose artefacts to represent challenging and/or landmark experiences, balanced by experiences that were joyful or fostered peer connection. Novelty influenced choice. To maximise learning students should draw from all experiences, to promote supported reflection with an advisor. Tasks should be timed to coincide with the introduction of new challenges.

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).

How does portfolio use support self-regulated learning during general practitioner specialty training? A qualitative focus group study.

OBJECTIVES: Portfolios are used to support self-regulated learning (SRL), but the research literature is still inconclusive on their effectiveness. This study explored experiences with portfolio use among different stakeholders, to answer the research question: How does portfolio use support SRL during general practitioner (GP) specialty training? DESIGN: We used a qualitative research design, based on phenomenology. SETTING: Three of the eight training institutes of Dutch GP specialty training participated in this study. PARTICIPANTS: The three stakeholder groups that use the portfolio were included in nine homogenous focus groups: trainees (n=16), supervisors (n=16) and faculty (n=17). All participants had at least 6-month experience with portfolio use. RESULTS: Three themes were identified: SRL with(out) the portfolio, stakeholder dynamics and ambiguities. Respondents were doubtful about the learning benefits of portfolio use, as most trainees used their portfolio to 'check off' what was considered required. Stakeholder dynamics contributed to checking off behaviour in two ways. First, trainees experienced documenting learning activities to be superfluous, since the close relationship with their supervisor already supported SRL sufficiently. Second, faculty often (unintentionally) took portfolio ownership away from trainees, as they instructed trainees to deliver portfolio content that was valuable for assessment. Without ownership, trainees struggled to use the portfolio for SRL. Besides, ambiguities related to portfolio use amplified checking off behaviour. CONCLUSIONS: Portfolio use did not support SRL in our setting. The multipurpose use of the portfolio (for the support of SRL and assessment) was identified as the primary obstacle. Underlying is a conflict that is often present in current medical curricula: agency versus accountability. If the support of SRL is considered a valuable and attainable purpose of portfolio use, it is important to realise that deliberate attention for this purpose is required during the design, guidance, assessment and evaluation of the portfolio.

Informed self-assessment during the transition to medical school: a longitudinal narrative study.

OBJECTIVES: To explore how medical students' narratives of informed self-assessment (ISA) change during their first 18 months of study. DESIGN: This longitudinal study used student narratives drawn from qualitative interviews and written reflections during the transition to medical school, to examine changes in ISA. Our analysis was informed by Situated Cognition Theory which recognises the impact and interplay of personal and environmental factors in cognition. SETTING: To study medicine, first year students need to adapt their self-regulated learning in the context of a new peer group, study demands and educational culture. During this adaptation, students need to seek and interpret available cues to inform their self-assessment. PARTICIPANTS: Longitudinal data were collected at five time points over 18 months from a diverse sample of seven first year medical students in an undergraduate medical programme, including 13.5 hours of interviews and 12 written reflections. RESULTS: Before and after starting medical school, the participants' self-assessments were informed by environmental influences (exam results and comparison with peers), and personal influences (fear of failure and anxiety about not belonging). Early uncertainty meant self-assessments were overestimated and underestimated.By the end of first year, an enhanced sense of belonging coincided with less fear of failure, less emphasis on exam performance and reduced competition with peers. Self-assessments became increasingly informed by evidence of clinical skills and knowledge gained related to future professional competence. CONCLUSION: Influences on medical students' ISAs change during the transition to studying medicine. A greater sense of belonging, and evidence of progress towards clinical competence became more important to self-assessment than comparison with peers and exam performance. Our findings reinforce the importance of formative assessments, opportunities to study and socialise with peers and early clinical experiences during first year. These experiences enhance ISA skills during the transition to medical school.

How does portfolio use affect self-regulated learning in clinical workplace learning: What works, for whom, and in what contexts?

INTRODUCTION: Portfolio use to support self-regulated learning (SRL) during clinical workplace learning is widespread, but much is still unknown regarding its effectiveness. This review aimed to gain insight in the extent to which portfolio use supports SRL and under what circumstances. METHODS: A realist review was conducted in two phases. First, stakeholder interviews and a scoping search were used to formulate a program theory that explains how portfolio use could support SRL. Second, an in-depth literature search was conducted. The included papers were coded to extract context-mechanism-outcome configurations (CMOs). These were synthesized to answer the research question. RESULTS: Sixteen papers were included (four fulfilled all qualitative rigor criteria). Two primary portfolio mechanisms were established: documenting as a moment of contemplation (learners analyze experiences while writing portfolio reports) and documentation as a reminder of past events (previous portfolio reports aid recall). These mechanisms may explain the positive relationship between portfolio use and self-assessment, reflection, and feedback. However, other SRL outcomes were only supported to a limited extent: formulation of learning objectives and plans, and monitoring. The partial support of the program theory can be explained by interference of contextual factors (e.g., system of assessment) and portfolio-related mechanisms (e.g., mentoring). DISCUSSION: Portfolio research is falling short both theoretically-in defining and conceptualizing SRL-and methodologically. Nevertheless, this review indicates that portfolio use has potential to support SRL. However, the working mechanisms of portfolio use are easily disrupted. These disruptions seem to relate to tensions between different portfolio purposes, which may undermine learners' motivation.

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.

Nicotine promotes vascular calcification via intracellular Ca2+-mediated, Nox5-induced oxidative stress, and extracellular vesicle release in vascular smooth muscle cells.

AIMS: Smokers are at increased risk of cardiovascular events. However, the exact mechanisms through which smoking influences cardiovascular disease resulting in accelerated atherosclerosis and vascular calcification are unknown. The aim of this study was to investigate effects of nicotine on initiation of vascular smooth muscle cell (VSMC) calcification and to elucidate underlying mechanisms. METHODS AND RESULTS: We assessed vascular calcification of 62 carotid lesions of both smoking and non-smoking patients using ex vivo micro-computed tomography (µCT) scanning. Calcification was present more often in carotid plaques of smokers (n = 22 of 30, 73.3%) compared to non-smokers (n = 11 of 32, 34.3%; P < 0.001), confirming higher atherosclerotic burden. The difference was particularly profound for microcalcifications, which was 17-fold higher in smokers compared to non-smokers. In vitro, nicotine-induced human primary VSMC calcification, and increased osteogenic gene expression (Runx2, Osx, BSP, and OPN) and extracellular vesicle (EV) secretion. The pro-calcifying effects of nicotine were mediated by Ca2+-dependent Nox5. SiRNA knock-down of Nox5 inhibited nicotine-induced EV release and calcification. Moreover, pre-treatment of hVSMCs with vitamin K2 ameliorated nicotine-induced intracellular oxidative stress, EV secretion, and calcification. Using nicotinic acetylcholine receptor (nAChR) blockers α-bungarotoxin and hexamethonium bromide, we found that the effects of nicotine on intracellular Ca2+ and oxidative stress were mediated by α7 and α3 nAChR. Finally, we showed that Nox5 expression was higher in carotid arteries of smokers and correlated with calcification levels in these vessels. CONCLUSION: In this study, we provide evidence that nicotine induces Nox5-mediated pro-calcific processes as novel mechanism of increased atherosclerotic calcification. We identified that activation of α7 and α3 nAChR by nicotine increases intracellular Ca2+ and initiates calcification of hVSMCs through increased Nox5 activity, leading to oxidative stress-mediated EV release. Identifying the role of Nox5-induced oxidative stress opens novel avenues for diagnosis and treatment of smoking-induced cardiovascular disease.

A dermatology E-learning programme is perceived as a valuable learning tool in postgraduate general practice training.

OBJECTIVES: This study aims to explore GP residents' knowledge retention and residents' and clinical teachers' perception on the learning value of a dermatology E-learning programme. METHODS: The study used a mixed-method design with a convergent parallel collection of data. GP residents (n=21) were selected through purposive sampling and were randomized to an E-learning group (n=12) or a traditional teaching methods group (n=9). The pre-and post-intervention knowledge tests of the E-learning group were compared using paired-samples t-tests. Post-knowledge tests scores of both groups were compared using independent t-tests. Cronbach's coefficient α was used to calculate the internal consistency of the questions used in the knowledge tests. Individual semi-structured interviews and clinical teachers (n=16) were conducted and analyzed using King's template analysis. RESULTS: The E-learning group showed a significant increase in mean knowledge test scores from 58.92% (SD=9.55%) to 64.92% (SD=13.65%) (t(11)=2.258, p=0.045, Cohen's d=0.51). The pre-knowledge test consisted of 46 items (Alpha=0.78), and the post-knowledge tests consisted of 45 items (Alpha=0.90). Interview data showed that the E-learning programme aided GP trainees' learning process and favoured a mixed-method teaching design, in which E-learning is used in parallel to the traditional teaching methods. CONCLUSIONS: A dermatology E-learning programme appeared an effective strategy in resident's knowledge acquiring. The key users' perceptions, both residents and clinical teachers, indicated that E-learning was feasible and helpful for learning processes. Further research is required to evaluate the implementation of E-learning programmes in parallel to regular teaching programs.

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.

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.

Sharing Reflections on Multisource Feedback in a Peer Group Setting: Stimulating Physicians' Professional Performance and Development.

PURPOSE: Reflecting on and using feedback are important for physicians' continuous professional development (CPD). A common format is the discussion of multisource feedback (MSF) in a one-on-one session with a trusted peer or coach. A new approach is to discuss MSF during a peer group session moderated by a professional facilitator. This qualitative study explored how physicians experience participation in these peer group sessions in the context of their CPD. METHOD: Between March and July 2018, 26 physicians were interviewed about their experiences in a peer group session. These physicians represented 13 monospecialty physician groups from 5 general hospitals in the Netherlands. Interviews were transcribed verbatim and analyzed iteratively, following the interpretative phenomenological approach. RESULTS: Participation was experienced as a process of disclosing and sharing personal reflections with peers while striking a balance between interpersonal proximity to and distance from peers. Sharing reflections with peers rendered the feedback more meaningful, deepened collegial relationships, and created a sense of urgency for improvement. Improvement goals were mostly related to relational fine-tuning in collaboration; goals related to individual career management remained in the background. Influential factors for the perceived effectiveness of the group sessions were related to the facilitator's expertise, group size, continuity and quality of collegial relationships, personal vulnerabilities, and the context of CPD policy. CONCLUSIONS: Peer group sessions offered interactivity and established a clear link between individual physicians and their work environments. Sharing reflections on MSF in a peer group setting provided physicians with nuanced insight into their professional performance and fostered a community spirit that supported the implementation of intended changes. Future research should focus on the role of group dynamics and communication strategies and the application of coaching principles, such as drawing up a detailed plan of action and monitoring the follow-up process.

When Feedback Backfires: Influences of Negative Discrepancies Between Physicians' Self and Assessors' Scores on Their Subsequent Multisource Feedback Ratings.

INTRODUCTION: With multisource feedback (MSF) physicians might overrate their own performance compared with scores received from assessors. However, there is limited insight into how perceived divergent feedback affects physicians' subsequent performance scores. METHODS: During 2012 to 2018, 103 physicians were evaluated twice by 684 peers, 242 residents, 999 coworkers, and themselves in three MSF performance domains. Mixed-effect models quantified associations between the outcome variable "score changes" between first and second MSF evaluations, and the explanatory variable "negative discrepancy score" (number of items that physicians rated themselves higher compared with their assessors' scores) at the first MSF evaluation. Whether associations differed across assessor groups and across a physician's years of experience as a doctor was analyzed too. RESULTS: Forty-nine percent of physicians improved their total MSF score at the second evaluation, as assessed by others. Number of negative discrepancies was negatively associated with score changes in domains "organization and (self)management" (b = -0.02; 95% confidence interval [CI], -0.03 to -0.02; SE = 0.004) and "patient-centeredness" (b = -0.03; 95% CI, -0.03 to -0.02; SE = 0.004). For "professional attitude," only negative associations between score changes and negative discrepancies existed for physicians with more than 6-year experience (b6-10yearsofexperience = -0.03; 95% CI, -0.05 to -0.003; SE = 0.01; b16-20yearsofexperience = -0.03; 95% CI, -0.06 to -0.004; SE = 0.01). DISCUSSION: The extent of performance improvement was less for physicians confronted with negative discrepancies. Performance scores actually declined when physicians overrated themselves on more than half of the feedback items. PA score changes of more experienced physicians confronted with negative discrepancies and were affected more adversely. These physicians might have discounted feedback due to having more confidence in own performance. Future work should investigate how MSF could improve physicians' performance taking into account physicians' confidence.

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.

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.

Where the rubber meets the road - An integrative review of programmatic assessment in health care professions education.

INTRODUCTION: Programmatic assessment was introduced as an approach to design assessment programmes with the aim to simultaneously optimize the decision-making and learning function of assessment. An integrative review was conducted to review and synthesize results from studies investigating programmatic assessment in health care professions education in practice. METHODS: The authors systematically searched PubMed, Web of Science, and ERIC to identify studies published since 2005 that reported empirical data on programmatic assessment. Characteristics of the included studies were extracted and synthesized, using descriptive statistics and thematic analysis. RESULTS: Twenty-seven studies were included, which used quantitative methods (n = 10), qualitative methods (n = 12) or mixed methods (n = 5). Most studies were conducted in clinical settings (77.8%). Programmatic assessment was found to enable meaningful triangulation for robust decision-making and used as a catalyst for learning. However, several problems were identified, including overload in assessment information and the associated workload, counterproductive impact of using strict requirements and summative signals, lack of a shared understanding of the nature and purpose of programmatic assessment, and lack of supportive interpersonal relationships. Thematic analysis revealed that the success and challenges of programmatic assessment were best understood by the interplay between quantity and quality of assessment information, and the influence of social and personal aspects on assessment perceptions. CONCLUSION: Although some of the evidence may seem compelling to support the effectiveness of programmatic assessment in practice, tensions will emerge when simultaneously stimulating the development of competencies and assessing its result. The identified factors and inferred strategies provide guidance for navigating these tensions.

Analysis of factors affecting Canadian medical students' success in the residency match.

BACKGROUND: In North America, there is limited data to support deliberate application strategies for post-graduate residency training. There is significant interest in determining what factors play a role in Canadian medical graduate (CMG) matching to their first choice discipline and heightened concern about the number of students going unmatched altogether. METHODS: We analyzed matching outcomes of CMGs based on seven years (2013-2019) of residency application data (n= 13,499) from the Canadian Residency Matching Service (CaRMS) database using descriptive and binary logistic regression modeling techniques. RESULTS: The sample was 54% female, with 60% between the ages of 26 and 29, and 60% attended medical schools in Ontario. Applicants who received more rankings from residency programs were more likely (OR = 1.185, p < 0.001) to match. Higher research activities (OR = 0.985, p < 0.001) and number of applications submitted (OR = 0.920, p < 0.001) were associated with a reduced likelihood of matching. Number of volunteer activities and self-report publications did not significantly affect matching. Being male (OR = 0.799, p < 0.05) aged <25 (OR = 0.756, p < 0.05), and from Eastern (OR = 0.497, p < 0.01), or Western (OR = 0.450, p < 0.001) Canadian medical schools were predictors of remaining unmatched. CONCLUSIONS: This study identified several significant associations of demographic and application factors that affected matching outcomes. The results will help to better inform medical student application strategies and highlight possible biases in the selection process.

CONTEXTE: En Amérique du Nord, les données qui soutiennent les stratégies délibérées de candidature pour la formation en résidence postdoctorale sont limitées. Il existe un intérêt important dans la détermination des facteurs qui jouent un rôle dans le jumelage des diplômés canadiens en médecine (DCM) à leur discipline de premier choix et dans les préoccupations croissantes au sujet du nombre d'étudiants non jumelés. MÉTHODES: Nous avons analysé les résultats des DCM sur une période de sept ans (2013-2019) à partir de données de demandes de résidence (n = 13 499) tirées de la base de données du Service canadien de jumelage des résidents (CaRMS) en utilisant des techniques de modélisation par régression logistique binaire. RÉSULTATS: L'échantillon comportait 54 % de femmes, avec 56 % âgées de 26 à 29 ans, et 60 % qui allaient à des facultés de médecine en Ontario. Les candidats qui avaient reçu plus de classements des programmes de résidences étaient plus susceptibles d'être jumelés (RC = 1,185, p < 0,001). Les activités scientifiques de pointe (RC = 0,985, p < 0,001) et un certain nombre de candidatures soumises (RC = 0,90, p < 0,001) étaient associées avec une probabilité réduite de jumelage. Un certain nombre d'activités bénévoles et des publications autodéclarées ne modifiaient pas le jumelage de manière importante. Être un homme (RC = 0,799, p < 0,05) âgé de moins de 25 ans (RC = 0,756, p < 0,05) et de facultés canadiennes de médecine de l'Est (RC = 0,497, p < 0,01) et de l'Ouest (RC = 0,450, p < 0,001) étaient des prédicteurs des candidatures non jumelées. CONCLUSIONS: Cette étude a établi plusieurs associations importantes de facteurs démographiques et de candidatures qui touchaient les résultats des jumelages. Les résultats aideront à mieux informer les stratégies de candidatures des étudiants en médecine et montrent les biais possibles dans le processus de sélection.