Clinical teaching self-efficacy positively predicts professional fulfillment and negatively predicts burnout amongst Thai physicians: a cross-sectional survey.

BACKGROUND: Clinician teachers (physicians who teach in clinical settings) experience considerable psychological challenges in providing both educational training and patient care. This study aimed to determine the prevalence of physician burnout and professional fulfillment, and to identify internal and external factors associated with mental health outcomes among Thai clinician teachers working in non-university teaching hospitals. METHOD: A one-time online questionnaire was completed by physicians at 37 governmental, non-university teaching hospitals in Thailand, with 227 respondents being assessed in the main analyses. Four outcomes were evaluated including burnout, professional fulfillment, quality of life, and intentions to quit. RESULTS: The observed prevalence of professional fulfillment was 20%, and burnout was 30.7%. Hierarchical regression analysis showed a significant internal, psychological predictor (clinical teaching self-efficacy) and external, structural predictors (multiple roles at work, teaching support), controlling for the background variables of gender, years of teaching experience, family roles, and active chronic disease, with clinical teaching self-efficacy positively predicting professional fulfillment (b = 0.29, p ≤.001) and negatively predicting burnout (b = - 0.21, p =.003). CONCLUSIONS: Results highlight the importance of faculty development initiatives to enhance clinical teaching self-efficacy and promote mental health among Thai physicians.

Defining new roles and competencies for administrative staff and faculty in the age of competency-based medical education.

PURPOSE: These authors sought to define the new roles and competencies required of administrative staff and faculty in the age of CBME. METHOD: A modified Delphi process was used to define the new CBME roles and competencies needed by faculty and administrative staff. We invited international experts in CBME (volunteers from the ICBME Collaborative email list), as well as faculty members and trainees identified via social media to help us determine the new competencies required of faculty and administrative staff in the CBME era. RESULTS: Thirteen new roles were identified. The faculty-specific roles were: National Leader/Facilitator in CBME; Institutional/University lead for CBME; Assessment Process & Systems Designer; Local CBME Leads; CBME-specific Faculty Developers or Trainers; Competence Committee Chair; Competence Committee Faculty Member; Faculty Academic Coach/Advisor or Support Person; Frontline Assessor; Frontline Coach. The staff-specific roles were: Information Technology Lead; CBME Analytics/Data Support; Competence Committee Administrative Assistant. CONCLUSIONS: The authors present a new set of faculty and staff roles that are relevant to the CBME context. While some of these new roles may be incorporated into existing roles, it may be prudent to examine how best to ensure that all of them are supported within all CBME contexts in some manner.

Questioning medical competence: Should the Covid-19 crisis affect the goals of medical education?

The COVID-19 pandemic has disrupted many societal institutions, including health care and education. Although the pandemic's impact was initially assumed to be temporary, there is growing conviction that medical education might change more permanently. The International Competency-based Medical Education (ICBME) collaborators, scholars devoted to improving physician training, deliberated how the pandemic raises questions about medical competence. We formulated 12 broad-reaching issues for discussion, grouped into micro-, meso-, and macro-level questions. At the individual micro level, we ask questions about adaptability, coping with uncertainty, and the value and limitations of clinical courage. At the institutional meso level, we question whether curricula could include more than core entrustable professional activities (EPAs) and focus on individualized, dynamic, and adaptable portfolios of EPAs that, at any moment, reflect current competence and preparedness for disasters. At the regulatory and societal macro level, should conditions for licensing be reconsidered? Should rules of liability be adapted to match the need for rapid redeployment? We do not propose a blueprint for the future of medical training but rather aim to provoke discussions needed to build a workforce that is competent to cope with future health care crises.

Understanding the lived experiences of medical learners in a narrative medicine course: a phenomenological study.

BACKGROUND: Reflection and various approaches to foster reflection have been regarded as an indispensable element in enhancing professional practice across different disciplines. With its inherent potential to engage learners in reflection and improvement, narrative medicine has been adopted in various settings. However, the relevance and effectiveness of reflection remains underexplored in the context of narrative medicine, specifically in regard to the concern about variability of learner acceptance and the way learners really make sense of these reflective activities. This study aimed to explore what medical learners experience through narrative medicine and the meanings they ascribe to the phenomenon of this narrative-based learning. METHODS: Using a transcendental phenomenology approach, twenty medical learners were interviewed about their lived experiences of taking a narrative medicine course during their internal medicine clerkship rotation. Moustakas' phenomenological analysis procedures were applied to review the interview data. RESULTS: Six themes were identified: feeling hesitation, seeking guidance, shifting roles in narratives, questioning relationships, experiencing transformation, and requesting a safe learning environment. These themes shaped the essence of the phenomenon and illustrated what and how medical learners set out on a reflective journey in narrative medicine. These findings elucidate fundamental elements for educators to consider how narrative approaches can be effectively used to engage learners in reflective learning and practice. CONCLUSION: Adopting Moustakas' transcendental phenomenology approach, a better understanding about the lived experiences of medical learners regarding learning in narrative medicine was identified. Learner hesitancy should be tackled with care by educators so as to support learners with strategies that address guidance, relationship, and learning environment. In so doing, medical learners can be facilitated to develop reflective capabilities for professional and personal growth.

The education avenue of the clinical learning environment: A pragmatic approach.

Aim: This perspective is part of a series of articles that are outcomes of a consensus conference, that seek to offer a comprehensive examination of the clinical learning environment (CLE), using different academic disciplines and areas of focus termed "avenues." The education dimensions of the CLE are discussed in detail in this perspective, along with critical linkages to the other avenues. Methods: Using iterative presentations, discussion and small group work, in October 2018, the consensus conference participants explored the education, psychological, sociocultural, diversity and inclusion, digital and architectural aspects of the CLE. Results: The education avenue of the CLE includes elements of teaching and learning such as the curriculum, clinical experiences, the assessment system, educational program governance, trainee selection, faculty development, and program evaluation and improvement. Within the educational domain, we focus on organizational and personal/social aspects of the CLE, including (1) curriculum design and deployment, including placement of trainees in clinical settings, organizational culture, practices and policies, and accreditation and regulatory requirements from the organizational domain (2) the education system, including assessment, program evaluation and organization and governance; and (3) elements from the personal and social domains, including peer-to-peer, trainee-faculty, and trainee-patient relationships that influence how and what postgraduate trainees learn, trainee selection, informal and hidden curricula, and trainees' perceptions of their learning environment. Conclusions: We provide suggestions for further research and recommendations for addressing challenges and facilitating improvement in the educational aspects of the CLE, along with actionable practice points.

The clinical learning environment.

Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. The subject of the clinical learning environment (CLE) is at the forefront of discussions. In this introduction to a themed issue on the CLE, we present an expanded conceptual model that approaches the CLE through six different lenses, termed "avenues:" architectural, digital, diversity and inclusion, education, psychological, and sociocultural, with each avenue represented by a paper. The aim is to facilitate dialog around the contributions of different academic disciplines to research on the CLE. Collectively the papers highlight the overlap between the various "avenues" in how they influence each other, and how they collectively have shaped the work to understand and improve the CLE. The expectation is that the various avenues can add to existing knowledge and create new ideas for interventions to improve the clinical learning environment across nations for learners and teachers with the ultimate aim of improving patient care. Research and efforts to improve the CLE are critical to learning, professional socialization and well-being for trainees as they learn and participate in patient care, and to the quality of care they will deliver over decades of practice after graduation.

Twelve tips for promoting learning during presentations in cross cultural settings.

Educators frequently learn together in cross cultural settings such as at international conferences. Cultural differences should influence how educational programs are designed and delivered to effectively support learning; cultural sensitivity and the competence to deal with such differences are important skills for health professions educators. Teaching without this approach may lead to lost learning opportunities. This article provides twelve tips for educators to consider when planning and delivering formal presentations (e.g. lectures and workshops) in cross cultural settings. The tips were constructed based on a literature review, the authors' experience, and interviews with international educators who frequently deliver and receive education in cross cultural settings. The tips are divided into three phases: (1) preparation for the session to optimize learners' experience (2) interaction when delivering the session and (3) reflection on the experience.

Implementing competency-based medical education: Moving forward.

For more than 60 years, competency-based education has been proposed as an approach to education in many disciplines. In medical education, interest in CBME has grown dramatically in the last decade. This editorial introduces a series of papers that resulted from summits held in 2013 and 2016 by the International CBME Collaborators, a scholarly network whose members are interested in developing competency-based approaches to preparing the next generation of health professionals. An overview of the papers is given, as well as a summary of landmarks in the conceptual evolution and implementation of CBME. This series follows on a first collection of papers published by the International CBME Collaborators in Medical Teacher in 2010.

Changing the culture of medical training: An important step toward the implementation of competency-based medical education.

OBJECTIVE: The current medical education system is steeped in tradition and has been shaped by many long-held beliefs and convictions about the essential components of training. The objective of this article is to propose initiatives to overcome biases against competency-based medical education (CBME) in the culture of medical education. MATERIALS AND METHODS: At a retreat of the International Competency Based Medical Education (ICBME) Collaborators group, an intensive brainstorming session was held to determine potential barriers to adoption of CBME in the culture of medical education. This was supplemented with a review of the literature on the topic. RESULTS: There continues to exist significant key barriers to the widespread adoption of CBME. Change in educational culture must be embraced by all components of the medical education hierarchy. Research is essential to provide convincing evidence of the benefit of CBME. CONCLUSIONS: The widespread adoption of CBME will require a change in the professional, institutional, and organizational culture surrounding the training of medical professionals.

Competency-based medical education and continuing professional development: A conceptualization for change.

Competency-based medical education (CBME) is as important in continuing professional development (CPD) as at any other stage of a physician's career. Principles of CBME have the potential to revolutionize CPD. Transitioning to CBME-based CPD will require a cultural change to gain commitment from physicians, their employers and institutions, CPD providers, professional organizations, and medical regulators. It will require learning to be aligned with professional and workplace standards. Practitioners will need to develop the expertise to systematically examine their own clinical performance data, identify performance improvement opportunities and possibilities, and develop a plan to address areas of concern. Health care facilities and systems will need to produce data on a regular basis and to develop and train CPD educators who can work with physician groups. Stakeholders, such as medical regulatory authorities who are responsible for licensing physicians and other standard-setting bodies that credential and develop maintenance-of-certification systems, will need to change their paradigm of competency enhancement through CPD.

Toward a shared language for competency-based medical education.

The paradigm shift brought about by the advent of competency-based medical education (CBME) can be characterized as an adaptive change. Currently, its development and implementation suffer from the lack of a lingua franca. A shared language is needed to support collaboration and dissemination across the world community of medical educators. The International CBME Collaborators held a second summit in 2013 to explore this and other contemporary CBME issues. We present the resulting International CBME Collaborator's glossary of CBME terms. Particular attention is given to the terms competency, entrustable professional activity (EPA), and milestone and their interrelationships. Medical education scholars and enthusiasts of the competency-based approach are encouraged to adopt these terms and definitions, although no doubt the vocabulary of CBME will continue to evolve.

A call to action: The controversy of and rationale for competency-based medical education.

Although medical education has enjoyed many successes over the last century, there is a recognition that health care is too often unsafe and of poor quality. Errors in diagnosis and treatment, communication breakdowns, poor care coordination, inappropriate use of tests and procedures, and dysfunctional collaboration harm patients and families around the world. These issues reflect on our current model of medical education and raise the question: Are physicians being adequately prepared for twenty-first century practice? Multiple reports have concluded the answer is "no." Concurrent with this concern is an increasing interest in competency-based medical education (CBME) as an approach to help reform medical education. The principles of CBME are grounded in providing better and safer care. As interest in CBME has increased, so have criticisms of the movement. This article summarizes and addresses objections and challenges related to CBME. These can provide valuable feedback to improve CBME implementation and avoid pitfalls. We strongly believe medical education reform should not be reduced to an "either/or" approach, but should blend theories and approaches to suit the needs and resources of the populations served. The incorporation of milestones and entrustable professional activities within existing competency frameworks speaks to the dynamic evolution of CBME, which should not be viewed as a fixed doctrine, but rather as a set of evolving concepts, principles, tools, and approaches that can enable important reforms in medical education that, in turn, enable the best outcomes for patients.

Evolving concepts of assessment in a competency-based world.

Competency-based medical education (CBME) is an approach to the design of educational systems or curricula that focuses on graduate abilities or competencies. It has been adopted in many jurisdictions, and in recent years an explosion of publications has examined its implementation and provided a critique of the approach. Assessment in a CBME context is often based on observations or judgments about an individual's level of expertise; it emphasizes frequent, direct observation of performance along with constructive and timely feedback to ensure that learners, including clinicians, have the expertise they need to perform entrusted tasks. This paper explores recent developments since the publication in 2010 of Holmboe and colleagues' description of CBME assessment. Seven themes regarding assessment that arose at the second invitational summit on CBME, held in 2013, are described: competency frameworks, the reconceptualization of validity, qualitative methods, milestones, feedback, assessment processes, and assessment across the medical education continuum. Medical educators interested in CBME, or assessment more generally, should consider the implications for their practice of the review of these emerging concepts.

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.

"In our own words": Defining medical professionalism from a Latin American perspective.

BACKGROUND: Latin America has experienced a tremendous growth in a number of medical schools, and there are concerns about their quality of training in critical areas such as professionalism. Medical professionalism is a cultural construct. The aim of the study was to compare published definitions of medical professionalism from Latin American and non-Latin American regions and to design an original and culturally sound definition. METHODS: A mixed methods approach was used with three phases. First, a systematic search and thematic analysis of the literature were conducted. Second, a Delphi methodology was used to design a local definition of medical professionalism. Third, we used a qualitative approach that combined focus groups and personal interviews with students and deans from four medical schools in Chile to understand various aspects of professionalism education. The data were analyzed using NVivo software. RESULTS: A total of 115 nonrepeated articles were identified in the three databases searched. No original definitions of medical professionalism from Latin America were found. Twenty-six articles met at least one of the three decisional criteria defined and were fully reviewed. Three theoretical perspectives were identified: contractualism, personalism, and deontology. Attributes of medical professionalism were classified in five dimensions: personal, interpersonal, societal, formative, and practical. Participants of the Delphi panel, focus groups, and personal interviews included 36 medical students, 12 faculties, and four deans. They took a personalistic approach to design an original definition of medical professionalism and highlighted the relevance of respecting life, human dignity, and the virtue of prudence in medical practice. Students and scholars differed on the value given to empathy and compassion. DISCUSSION: This study provides an original and culturally sound definition of medical professionalism that could be useful in Latin American medical schools. The methodology used in the study could be applied in other regions as a basis to develop culturally appropriate definitions of medical professionalism.

Patient-centred education: what do students think?

CONTEXT: Medical educators endeavour to foster patient-centred learning. Although studies of patient-educators report general increases in patient-centredness, no formal review of students' reflections on the role of patients in their education has yet been undertaken. Our research questions were: (i) What themes might be identified through a qualitative analysis of students' reflective writing on patient-centred education? (ii) What are common students' perceptions regarding patients as educators? METHODS: For two academic years, Year 2 pre-clinical students (189 and 167 students, respectively, in each academic year) submitted a 250-word writing assignment in response to one of four questions meant to promote reflection on the role of patients in their education. Using a grounded theory approach, we performed a qualitative analysis of these written reflections for emerging themes. A synthesis of these themes was prepared and was presented for validation and discussion by two focus groups of six and three students, respectively. We analysed the transcripts of the focus group discussions and compared them with results from the analysis of written reflections and used them to further inform and refine our initial thematic framework. RESULTS: A total of 356 reflective writing assignments were analysed. The major themes were: (i) students seeing the condition within the context of patients' lives; (ii) patients supporting students' learning; (iii) students recognising patients' needs; (iv) students seeing the patient as a capable part of the team, and (v) students recognising the complexity of practising medicine. The two focus group discussions confirmed these main themes, but placed greater emphasis on the first and second themes. These themes mapped closely to the conceptualisation of patient-centred care defined by the International Alliance of Patients' Organizations. CONCLUSIONS: Students' reflections on their experiences of patient-educators cover an important and broad range of key concepts in patient-centred care that are well aligned with patient-generated conceptualisations of patient-centred care.