Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review.

OBJECTIVE: We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented. DESIGN: We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance. DATA SOURCES: We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022. ELIGIBILITY CRITERIA: We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs' training was described. DATA EXTRACTION AND SYNTHESIS: The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency. RESULTS: Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes. CONCLUSION: This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations. PROSPERO REGISTRATION NUMBER: CRD42022369208.

Constructing "Burnout": A Critical Discourse Analysis of Burnout in Postgraduate Medical Education.

PURPOSE: In 1974, Dr. Herbert Freudenberger coined the term burnout. With the creation of the Maslach Burnout Inventory in 1984, burnout went from a pop psychology term to a highly studied phenomenon in medicine. Exponential growth in studies of burnout culminated in its adoption into the International Classification of Diseases-11 in 2022. Yet, despite increased awareness and efforts aimed at addressing burnout in medicine, many surveys report burnout rates have increased among trainees. The authors aimed to identify different discourses that legitimate or function to mobilize burnout in postgraduate medical education (PGME), to answer the question: Why does burnout persist in PGME despite efforts to ameliorate it? METHOD: Using a Foucauldian discourse analysis, this study examined the socializing period of PGME as an entry point into burnout's persistence. The archive from which the discourses were constructed included over 500 academic articles, numerous policy documents, autobiographies, videos, documentaries, social media, materials from conferences, and threads in forums including Reddit. RESULTS: This study identified 3 discourses of burnout from 1974-2019: burnout as illness, burnout as occupational stress, and burnout as existentialism. Each discourse was associated with statements of truth, signs and signifiers, roles that individuals play within the discourse, and different institutions that gained visibility as a result of differing discourses. CONCLUSIONS: Burnout persists despite effort to ameliorate it because it is a productive construct for organizations. In its current form, it depoliticizes issues of health in favor of wellness and gives voice to the challenge of making meaning from the experience of being a clinician.

Understanding how and why upskilling programmes for unregulated care providers can support health equity in underserved communities: a realist review protocol.

INTRODUCTION: Foot ulcers are one of the most devastating complications of diabetes mellitus leading to leg amputations. In Canada, systematically marginalised and racialised populations are more prone to developing foot ulcers and at higher risk of limb amputations. Shortages of regulated healthcare have hindered efforts to provide foot care. Upskilling unregulated care providers (UCPs) to deliver foot screening seems a reasonable solution to reduce limb loss. UCPs can advocate for health equity and deliver appropriate care. There is a need, however, to understand how and why an educational intervention for UCPs providing foot screening for these high-risk groups may or may not work. METHODS AND ANALYSIS: This realist review will follow the Realist And Meta-narrative Evidence Syntheses: Evolving Standards standards. First, we will develop an initial programme theory (PrT) based on exploratory searches and discussions with experts and stakeholders. Then, we will search MEDLINE, Embase, PsycINFO, ERIC, CINAHL and Scopus databases along with relevant sources of grey literature. The retrieved articles will be screened for studies focusing on planned educational interventions for UCPs related to diabetic foot assessment. Data regarding contexts, mechanisms and outcomes will be extracted and analysed using a realist analysis through an iterative process that includes data reviewing and consultation with our team. Finally, we will use these results to modify the initial PrT. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. The main output of this research will be an evidence-based PrT for upskilling programmes for UCPs. We will share our final PrT using text, tables and infographics to summarise our results and draw insights across papers/reports. For academic, clinical, social care and educational audiences, we will produce peer-reviewed journal articles, including those detailing the process and findings of the realist review and establishing our suggestions for effective upskilling programmes. PROSPERO REGISTRATION NUMBER: CRD42022369208.

Physician Champions of Quality and Safety: Perspectives of MD Quality and Safety Leads to Drive Quality Innovation at an Academic Hospital.

While the importance of physician involvement in organizational quality and safety (Q&S) activities has been well established, a paucity of information exists on tangible supports needed to effectively execute this role. Interviews with 13 MD Q&S leads uncovered common enablers, including valuing Q&S work academically, hiring skilled collaborators, ensuring appropriate power and authority to advance Q&S initiatives, facilitating connections, emphasizing culture change and strong action by leadership. To operationalize these enablers and drive quality innovation, organizations should prioritize the identification and appointment of MD Q&S leads for each department/division and facilitate their assembly as a formal physician Q&S committee.

Health Care Professional Association Agency in Preparing for Artificial Intelligence: Protocol for a Multi-Case Study.

BACKGROUND: The emergence of artificial intelligence (AI) in health care has impacted health care systems, including employment, training, education, and professional regulation. It is incumbent on health professional associations to assist their membership in defining and preparing for AI-related change. Health professional associations, or the national groups convened to represent the interests of the members of a profession, play a unique role in establishing the sociocultural, normative, and regulative elements of health care professions. OBJECTIVE: The aim of this paper is to present a protocol for a proposed study of how, when faced with AI as a disruptive technology, health professional associations engage in sensemaking and legitimization of change to support their membership in preparing for future practice. METHODS: An exploratory multi-case study approach will be used. This study will be informed by the normalization process theory (NPT), which suggests behavioral constructs required for complex change, providing a novel lens through which to consider the agency of macrolevel actors in practice change. A total of 4 health professional associations will be studied, each representing an instrumental case and related fields selected for their early consideration of AI technologies. Data collection will consist of key informant interviews, observation of relevant meetings, and document review. Individual and collective sensemaking activities and action toward change will be identified using stakeholder network mapping. A hybrid inductive and deductive model will be used for a concurrent thematic analysis, mapping emergent themes against the NPT framework to assess fit and identify areas of discordance. RESULTS: As of January 2021, we have conducted 17 interviews, with representation across the 4 health professional associations. Of these 17 interviews, 15 (88%) have been transcribed. Document review is underway and complete for one health professional association and nearly complete for another. Observation opportunities have been challenged by competing priorities during COVID-19 and may require revisiting. A linear cross-case analytic approach will be taken to present the data, highlighting both guidance for the implementation of AI and implications for the application of NPT at the macro level. The ability to inform consideration of AI will depend on the degree to which the engaged health professional associations have considered this topic at the time of the study and, hence, what priority it has been assigned within the health professional association and what actions have been taken to consider or prepare for it. The fact that this may differ between health professional associations and practice environments will require consideration throughout the analysis. CONCLUSIONS: Ultimately, this protocol outlines a case study approach to understand how, when faced with AI as a disruptive technology, health professional associations engage in sensemaking and legitimization of change to support their membership in preparing for future practice. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27340.

Reimagining Bias: Making Strange With Disclosure.

ABSTRACT: Academic presentations in health professions continuing professional development (CPD) often begin with a declaration of real or potential conflicts utilizing a three-slide template or a similar standardized display. These declarations are required in some constituencies. The three-slide template and similar protocols exist to assure learners that the content that follows has been screened, is notionally bias free, and without financial or other influence that might negatively affect health provider behavior. We suggest that there is a potential problem with this type of process that typically focusses in on a narrow definition of conflict of interest. There is the possibility that it does little to confront the issue that bias is a much larger concept and that many forms of bias beyond financial conflict of interest can have devastating effects on patient care and the health of communities. In this article, we hope to open a dialogue around this issue by "making the familiar strange," by asking education organizers and providers to question these standard disclosures. We argue that other forms of bias, arising from the perspectives of the presenter, can also potentially change provider behavior. Implicit biases, for example, affect relationships with patients and can lead to negative health outcomes. We propose that CPD reimagine the process of disclosure of conflicts of interest. We seek to expand reflection on, and disclosure of, perspectives and biases that could affect CPD learners as one dimension of harnessing the power of education to decrease structural inequities.

An Education Framework for Effective Implementation of a Health Information System: Scoping Review.

BACKGROUND: To optimize their use of a new Health Information System (HIS), supporting health care providers require effective HIS education. Failure to provide this education can significantly hinder an organization's HIS implementation and sustainability efforts. OBJECTIVE: The aim of this review is to understand the most effective educational strategies and approaches to enable health care providers to optimally use an HIS. METHODS: Ovid MEDLINE, Ovid Embase, EBSCO Cumulative Index to Nursing and Allied Health Literature, and EBSCO Education Resources Information Center were searched to identify relevant papers. Relevant studies were systematically reviewed and analyzed using a qualitative thematic analysis approach. RESULTS: Of the 3539 studies screened, 17 were included for data extraction. The literature on the most effective approaches to enable health care providers to optimally use an HIS emphasized the importance of investing in engaging and understanding learners in the clinical context, maximizing the transfer of learning to care, and designing continuous and agile evaluation to meet the emerging demands of the clinical environment. CONCLUSIONS: This review supports the advancement of a new HIS learning framework that organizational leaders and educators can use to guide HIS education design and development. Future research should examine how this framework can be translated into practice.

Should Wellness Be a Core Competency for Physicians?

There has been a recent rise in calls for action around wellness and physician health. In medical education, wellness has been proposed as a physician competency. In this article, the authors review the history of the "wellness as a competency" concept within U.S. and Canadian residency programs and medical schools. Drawing from literature on the discourses of wellness and competence in medical education, they argue that operationalizing wellness as a physician competency holds profound implications for curricula, admissions, evaluation, and licensure. While many definitions of "wellness" and "competency" are used within medical training environments, the authors argue that the definitions institutions ultimately use will have significant impacts for trainees who are considered "unwell." In particular, medical learners with disabilities-including those with mental health, chronic health, learning, sensory, and mobility disabilities-may not conform to dominant conceptions of "wellness," and there is a risk they will become further stigmatized or even be considered unsuitable to practice in the profession. The authors conclude that framing wellness as a competency has the potential to legitimize support-seeking and prioritize physician health, yet it may also have the potential unintended effect of excluding certain learners from the profession. They propose a universal design approach to understand wellness at a systems level and to remove barriers to wellness for all medical learners.

The Karolinska Institutet Prize for Research in Medical Education: A history.

Purpose: This article presents a history of the Karolinska Institutet Prize for Medical Education (KIPRIME), highlighting the history of, and influences on, its funders Drs. Gunnar Höglund and Anna-Stina Malmborg.Methods: Historic analysis of an archive of documents developed by the authors in a prior study exploring philanthropy in medical education research. Documents in the archive were drawn from publicly available Internet sources, media reports about the KIPRIME and its winners and an interview with Drs. Höglund's and Malmborg. The latter interview was conducted with Ethics Board approval in non-anonymous fashion and with the explicit permission of the interviewees to present their personal information and to cite their words. Finally, observations were shaped iteratively by the authors on multiple trips to the Karolinska Institutet with input from the KIPRIME prize committee leaders.Findings: The results of this analysis present a history of the prize situating it in the personal histories of, and influences acting upon, Drs. Höglund and Malmborg. Special attention is given to the potential influence of the Nobel Prizes and the culture of philanthropy in Sweden.

Beyond the cultural myth of medical meritocracy.

BACKGROUND: We examine the cultural myth of the medical meritocracy, whereby the "best and the brightest" are admitted and promoted within the profession. We explore how this narrative guides medical practice in ways that may no longer be adequate in the contexts of practice today. METHODS: Narrative analysis of medical students' and physicians' stories. RESULTS: Hierarchies of privilege within medicine are linked to meritocracy and the trope of the "hero's story" in literature. Gender and other forms of difference are generally excluded from narratives of excellence, which suggests operative mechanisms that may be contributory to observed differences in attainment. We discuss how the notion of diversity is formulated in medicine as a "problem" to be accommodated within merit, and posit that medical practice today requires a reformulation of the notion of merit in medicine, valorising a diversity of life experience and skills, rather than "retrofitting" diversity concerns as problems to be accommodated within current constructs of merit. CONCLUSIONS: Three main action-oriented outcomes for a better formulation of merit relevant to medical practice today are suggested: (a) development of assessors' critical consciousness regarding the structural issues in merit assignment; (b) alignment of merit criteria with relevant societal outcomes, and (c) developing inclusive leadership to accommodate the greater diversity of excellence needed in today's context of medical practice. A reformulation of the stories through which medical practitioners and educators communicate and validate aspects of medical practice will be required in order for the profession to continue to have relevance to the diverse societies it serves.

Why We Needn't Fear the Machines: Opportunities for Medicine in a Machine Learning World.

Recently in medicine, the accuracy of machine learning models in predictive tasks has started to meet or exceed that of board-certified specialists. The ability to automate cognitive tasks using software has raised new questions about the future role of human physicians in health care. Emerging technologies can displace people from their jobs, forcing them to learn new skills, so it is clear that this looming challenge needs to be addressed by the medical education system. While current medical education seeks to prepare the next generation of physicians for a rapidly evolving health care landscape to meet the needs of the communities they serve, strategic decisions about disruptive technologies should be informed by a deeper investigation of how machine learning will function in the context of medicine. Understanding the purpose and strengths of machine learning elucidates its implications for the practice of medicine. An economic lens is used to analyze the interaction between physicians and machine learning. According to economic theory, competencies that are complementary to machine prediction will become more valuable in the future, while competencies that are substitutes for machine prediction will become less valuable. Applications of machine learning to highly specific cognitive tasks will increase the performance and value of health professionals, not replace them. To train physicians who are resilient in the face of potential labor market disruptions caused by emerging technologies, medical education must teach and nurture unique human abilities that give physicians a comparative advantage over computers.

Assessment of professionalism: From where have we come - to where are we going? An update from the Ottawa Consensus Group on the assessment of professionalism.

BACKGROUND: In 2009, an International Working Group (IWG) on the Assessment of Professionalism began collaborating and published recommendations in 2011. Nearly a decade later the IWG reconvened to take stock of the state of practice and research in professionalism and the impact of the 2011 report. METHOD: A bibliometric study identified all publications on assessment of professionalism since 2011, noting those that cited the original report. Articles were coded to identify the reason for citation and new trends in assessment. Bibliometric data were supplemented by discussion groups held at key international education meetings. RESULTS: Six-hundred publications on the assessment of professionalism were found in Google Scholar and 164 in Web of Science since 2011, of which 177 (30%) and 84 (50%) respectively cited the original IWG publication. English language publications were most common (83%), but there were articles in 13 other languages by authors from 40 countries. The report was cited commonly to justify attention to professionalism in general (41%), assessment of professionalism (38%) and to explore professionalism in different countries and professions (25%). A thematic analysis showed that of 9 research areas recommended in 2011, 7 of 9 categories were represented with a large increase in research across languages and cultures. CONCLUSIONS: Though the assessment of professionalism remains a challenge the research base continues to grow, especially related to professionalism across cultures and languages, and a large percentage of publications cite the IWG recommendations. There remains a gap in research and writing about patients' perspectives.

Toronto Addis Ababa Academic Collaboration: A Relational, Partnership Model for Building Educational Capacity Between a High- and Low-Income University.

Educational partnerships between academic health sciences centers in high- and low-resource settings are often formed as attempts to address health care disparities. In this Perspective, the authors describe the Toronto Addis Ababa Academic Collaboration (TAAAC), an educational partnership between the University of Toronto and Addis Ababa University. The TAAAC model was designed to help address an urgent need for increased university faculty to teach in the massive expansion of universities in Ethiopia. As TAAAC has developed and expanded, faculty at both institutions have recognized that the need to understand contextual factors and to have clarity about funding, ownership, expertise, and control are essential elements of these types of collaborative initiatives. In describing the TAAAC model, the authors aim to contribute to wider conversations and deeper theoretical understandings about these issues.

The International Partner as Invited Guest: Beyond Colonial and Import-Export Models of Medical Education.

The dominant model of international collaboration in medical education, both currently and in the past two centuries, is one of foreign (i.e., Euro-American) ownership and control. In this Invited Commentary, the authors provide a brief selected history of such international partnerships. They then focus on recent partnership models that have alternative structures. One of these is the collaborative partnership between Addis Ababa University (AAU) and the University of Toronto. This partnership is known as the Toronto Addis Ababa Academic Collaboration (TAAAC). From the inception of this partnership, the TAAAC has aimed to be relational and has firmly placed ownership of the codeveloped curriculum at AAU. Other explicit aims of the TAAAC are to help AAU develop culturally appropriate programming that is sustainable with local resources and to develop capacity-building, coteaching models. In seeking potential precedents to the TAAAC, the authors have explored archives in Ethiopia, Canada, and the United Kingdom. They found that invited foreign guests have played a role in the development of educational systems in Ethiopia since the 1940s. The authors believe that by paying close attention to the language used to describe the nature of a relationship, medical educators may be able to move toward more collaborative, capacity-building international partnerships.

Twelve tips for undertaking reflexive global health experiences in medicine.

BACKGROUND: While interest and opportunities for global health experiences (GHE) continue to grow, the preparation of students and health professionals alike to engage in these GHEs remains limited. AIMS: This article provides tips for reflexivity prior to undertaking a GHE and suggests ways to debrief the experience in order to ensure that trainees and professionals that engage in GHEs can both help their intended communities and also get the most out of the experience. METHODS: The authors conducted a scoping review using Medline, PubMed and Google scholar using searching the terms: global health, global health experience, global health research, and international medical elective. We supplemented this search with our own experiences working with international partners. CONCLUSIONS: GHEs should be undertaken with reflexivity prior to, during and subsequent to the experience in order to ensure that all collaborators in the partnership meet their intended goals.

Toward a research agenda for competency-based medical education.

Competency-based medical education (CBME) is both an educational philosophy and an approach to educational design. CBME has already had a broad impact on medical schools, residency programs, and continuing professional development in health professions around the world. As the CBME movement evolves and CBME programs are implemented, a wide range of emerging research questions will warrant scholarly examination. In this paper, we describe a proposed CBME research agenda developed by the International CBME Collaborators. The resulting framework includes questions about the meaning of key concepts of CBME and their implications for learners, faculty members, and institutional structures. Other research questions relate to the learning process, the meaning of entrustment decisions, fundamental measurement issues, and the nature and definition of standards. The exploration of these questions will help to solidify the theoretical foundation of CBME, but many issues related to implementation also need to be addressed. These pertain to, among other things, nurturing independent learning, assembling and using assessment results to make decisions about competence, structuring feedback, supporting remediation, and how best to evaluate the longer-term outcomes of CBME. High-quality research on these questions will require rigorous outcome measures with strong validity evidence. The complexity of CBME necessitates theoretical and methodological diversity. It also requires multi-institutional studies that examine effects at multiple levels, from the learner to the team, the institution, and the health care system. Such a framework of research questions can guide and facilitate scholarly discourse on the theoretical and practical body of knowledge related to competency-based health professions education.