A narrative inquiry into non-Indigenous medical educators and leaders participation in reconcilatory work.

INTRODUCTION: Globally, medical schools are operationalising policies and programming to address Indigenous health inequities. Although progress has been made, challenges persist. In Canada, where this research is conducted, Indigenous representation within medical schools remains low, leaving a small number of Indigenous advocates leading unprecedented levels of equity-related work, often with insufficient resources. The change needed within medical education cannot fall solely on the shoulders of Indigenous Peoples; non-Indigenous Peoples must also be involved. This work aims to better understand the pathways of those engaged in this work, with careful consideration given to the facilitators and barriers to ongoing engagement. METHODS: Data collection and analysis were informed by narrative inquiry, a methodology that relies on storytelling to uncover nuance and prompt reflection. In this paper, we focus on interview data collected from Canadian non-Indigenous medical educators and leaders (n = 10). Participants represented different career stages, (early to late career) and occupied a mix of clinical, administrative and education roles. RESULTS: Although each participant's entry into reconciliatory work was unique, we identified common drivers actuating their engagement. Oftentimes their participation was tied to administrative work or propelled by experiences within their roles that forced them to confront the systemic inequalities borne by Indigenous Peoples in both academic and healthcare settings. Some admitted to struggling with understanding their appropriate role in Indigenous reconciliation; their participation often proceeded without firm support. CONCLUSION: Medical schools have an obligation to ensure their faculty, including non-Indigenous Peoples, are equipped to fulfil social accountability mandates regarding Indigenous health. Our findings generate a better understanding of the tensions inherent in this equity work. We urge others to reflect on their role in Indigenous reconciliation, or else medical schools risk generating a false sense of individual and institutional progress.

Navigating the burden of proof and responsibility: A narrative inquiry into Indigenous medical learners' experiences.

INTRODUCTION: Many medical schools have well-established admission pathways and programming to support Indigenous medical workforce development. Ideally, these efforts should contribute to attracting highly qualified Indigenous applicants which, in turn, may improve accessible, quality care for Indigenous people. However, it is difficult to evolve and tailor these approaches without a situated understanding of Indigenous learners' experiences. In this paper, we focus on the Canadian context, sharing Indigenous learners' stories about their journey towards and throughout medical training. METHODS: The conceptual underpinnings of narrative inquiry and key principles from Indigenous methodologies were drawn upon throughout both data collection and analysis. Participants were Indigenous learners (medical students and residents) and a recently graduated physician (n = 5) from one Canadian medical school. Both spoken (formal recorded interviews) and visual (photographs) texts were used to make meaning of participants' experiences. RESULTS: Participants' experiences during medical training showed a striking resemblance at three points in their transition to, and progression through, medical education: preparing for and applying to medical school, completing undergraduate medical training and determining specialty choice. Participants' stories revealed a tug-of-war between their identities as an Indigenous person and as a medical trainee, with these tensions sometimes compromising their perceived sense of belonging within both Indigenous and academic circles, creating, at times, a heavy burden to shoulder. CONCLUSION: Meaningful representation of Indigenous people in the medical workforce is about more than training additional health care providers; it requires understanding Indigenous learners and recently graduated physicians' experiences as they enter and navigate the medical profession. By amplifying their voices, we stand to gain a more holistic representation of the factors that contribute to and potentially impede the recruitment and retention of Indigenous people into the medical profession.

Expanding the advocacy lens: using photo-elicitation to capture patients' and physicians' perspectives about health advocacy.

Heath advocacy (HA) remains a difficult competency to train and assess, in part because practicing physicians and learners carry uncertainty about what HA means and we are missing patients' perspectives about the role HA plays in their care. Visual methods are useful tools for exploring nebulous topics in health professions education; using these participatory approaches with physicians and patients might counteract the identified training challenges around HA and more importantly, remedy the exclusion of patient perspectives. In this paper we share the verbal and visual reflections of patients and physicians regarding their conceptualizations of, and engagement in 'everyday' advocacy. In doing so, we reveal some of HA's hidden dimensions and what their images uncovered about the role of advocacy in patient care. Constructivist grounded theory guided data collection and analysis. Data was collected through semi-structured interviews and photo-elicitation, a visual research method that uses participant generated photographs to elicit participants knowledge and experiences around a particular topic. We invited patients living with chronic health conditions (n = 10) and physicians from diverse medical and surgical specialties (n = 14) to self-select photographs representing their experiences navigating HA in their personal and professional lives. Both groups found taking photographs useful for revealing the nuanced and circumstantial factors that either enabled or challenged their engagement in HA. While patients' photos highlighted their embodiment of HA, physicians' photos depicted HA as something quite elusive or as a complicated and daunting task. Photo-elicitation was a powerful tool in eliciting a diversity of perspectives that exist around the HA role and the work advocates perform; training programs might consider using visuals to augment teaching for this challenging competency.

Feedback and coaching.

If used thoughtfully and with intent, feedback and coaching will promote learning and growth as well as personal and professional development in our learners. Feedback is an educational tool as well as a social interaction between learner and supervisor, in the context of a respectful and trusting relationship. It challenges the learner's thinking and supports the learner's growth. Coaching is an educational philosophy dedicated to supporting learners' personal and professional development and growth and supporting them to reach their potential. In clinical education, feedback is most effective when it is explicitly distinguished from summative assessment. Importantly, feedback should be about firsthand observed behaviors (which can be direct or indirect) and not about information which comes from a third party. Learners are more receptive to feedback if it comes from a source that they perceive as credible, and with whom they have developed rapport. The coaching relationship between learner and supervisor should also be built on mutual trust and respect. Coaching can be provided in the moment (feedback on everyday clinical activities that leads to performance improvement, even with short interaction with a supervisor) and over time (a longer term relationship with a supervisor in which there is reflection on the learner's development and co-creation of new learning goals). Feedback and coaching are most valuable when the learner and teacher exhibit a growth mindset. At the organizational level, it is important that both the structures and training are in place to ensure a culture of effective feedback and coaching in the clinical workplace.Conclusions: Having a thoughtful and intentional approach to feedback and coaching with learners, as well as applying evidence-based principles, will not only contribute in a significant way to their developmental progression, but will also provide them with the tools they need to have the best chance of achieving competence throughout their training. What is Known: • Feedback and coaching are key to advancing the developmental progression of trainees as they work towards achieving competence. • Feedback is not a one-way delivery of specific information from supervisor to trainee, but rather a social interaction between two individuals in which trust and respect play a key role. • Provision of effective feedback may be hampered by confusing formative (supporting trainee learning and development) and summative (the judgment that is made about a trainee's level of competence) purposes. What is New: • Approaches to both the provision of feedback/coaching and the assessment of competence must be developed in parallel to ensure success in clinical training programs. • Faculty development is essential to provide clinical teachers with the skills to provide effective feedback and coaching. • Coaching's effectiveness relies on nurturing strong trainee-supervisor relationships, ensuring high-quality feedback, nourishing a growth mindset, and encouraging an institutional culture that embraces feedback and coaching.

The shift from disbelieving underperformance to recognising failure: A tipping point model.

CONTEXT: Coming face to face with a trainee who needs to be failed is a stern test for many supervisors. In response, supervisors have been encouraged to report evidence of failure through numerous assessment redesigns. And yet, there are lingering signs that some remain reluctant to engage in assessment processes that could alter a trainee's progression in the programme. Failure is highly consequential for all involved and, although rare, requires explicit study. Recent work identified a phase of disbelief that preceded identification of underperformance. What remains unknown is how supervisors come to recognise that a trainee needs to be failed. METHODS: Following constructivist grounded theory methodology, 42 physicians and surgeons in British Columbia, Canada shared their experiences supervising trainees who profoundly underperformed, required extensive remediation or were dismissed from the programme. We identified recurring themes using an iterative, constant comparative process. RESULTS: The shift from disbelieving underperformance to recognising failure involves three patterns: accumulation of significant incidents, discovery of an egregious error after negligible deficits or illumination of an overlooked deficit when pointed out by someone else. Recognising failure was accompanied by anger, certainty and a sense of duty to prevent harm. CONCLUSION: Coming to the point of recognising that a trainee needs to fail is akin to the psychological process of a tipping point where people first realise that noise is signal and cross a threshold where the pattern is no longer an anomaly. The co-occurrence of anger raises the possibility for emotions to be a driver of, and not only a barrier to, recognising failure. This warrants caution because tipping points, and anger, can impede detection of improvement. Our findings point towards possibilities for supporting earlier identification of underperformance and overcoming reluctance to report failure along with countermeasures to compensate for difficulties in detecting improvement once failure has been verified.

I, we and they: A linguistic and narrative exploration of the authorship process.

INTRODUCTION: While authorship plays a powerful role in the academy, research indicates many authors engage in questionable practices like honorary authorship. This suggests that authorship may be a contested space where individuals must exercise agency-a dynamic and emergent process, embedded in context-to negotiate potentially conflicting norms among published criteria, disciplines and informal practices. This study explores how authors narrate their own and others' agency in making authorship decisions. METHOD: We conducted a mixed-methods analysis of 24 first authors' accounts of authorship decisions on a recent multi-author paper. Authors included 14 females and 10 males in health professions education (HPE) from U.S. and Canadian institutions (10 assistant, 6 associate and 8 full professors). Analysis took place in three phases: (1) linguistic analysis of grammatical structures shown to be associated with agency (coding for main clause subjects and verb types); (2) narrative analysis to create a 'moral' and 'title' for each account; and (3) dialectic integration of (1) and (2). RESULTS: Descriptive statistics suggested that female participants used we subjects and material verbs (of doing) more than men and that full professors used relational verbs (of being and having) more than assistant and associate. Three broad types of agency were narrated: distributed (n = 15 participants), focusing on how resources and work were spread across team members; individual (n = 6), focusing on the first author's action; and collaborative (n = 3), focusing on group actions. These three types of agency contained four subtypes, e.g. supported, contested, task-based and negotiated. DISCUSSION: This study highlights the complex and emergent nature of agency narrated by authors when making authorship decisions. Published criteria offer us starting point-the stated rules of the authorship game; this paper offers us a next step-the enacted and narrated approach to the game.

Exploring patients' and physicians' perspectives about competent health advocacy.

INTRODUCTION: Many residency programmes struggle to demonstrate how they prepare trainees to become competent health advocates. To meaningfully teach and assess it, we first need to understand what 'competent' health advocacy (HA) is and what competently enacting it requires. Attempts at clarifying HA have largely centred around the perspectives of consultant physicians and trainees. Without patients' perspectives, we risk training learners to advocate in ways that may be misaligned with patients' needs and goals. Therefore, the purpose of our research was to generate a multi-perspective understanding about the meaning of competence for the HA role. METHODS: We used constructivist grounded theory to explore patients' and physicians' perspectives about competent health advocacy. Data were collected using photo elicitation; patients (n = 10) and physicians (n = 14) took photographs depicting health advocacy that were used to inform semi-structured interviews. Themes were identified using constant comparative analysis. RESULTS: Physician participants associated HA with disruption or political activism, suggesting that competence hinged on medical and systems expertise, a conducive learning environment, and personal and professional characteristics including experience, status and political savvy. Patient participants, however, equated physician advocacy with patient centredness, perceiving that competent HAs are empathetic and attentive listeners. In contrast to patients, few physicians identified as advocates, raising questions about their ability to train or to thoughtfully assess learners' abilities. CONCLUSION: Few participants perceived HA as a fundamental physician role-at least not as it is currently defined in curricular frameworks. Misperceptions that HA is primarily disruptive may be the root cause of the HA problem; solving it may rely on focusing training on bolstering skills like empathy and listening not typically associated with the HA role. Since there may be no competency where the patient voice is more critical, we need to explore opportunities for patients to facilitate learning for the HA role.

Getting airtime: Exploring how patients shape the stories they tell health practitioners.

INTRODUCTION: Effective communication during health encounters is known to decrease patient complaints, increase patient adherence and optimise health outcomes. While the aim of patient-centred care is to find common ground, health practitioners tend to drive the encounter, often interrupting patients within the first minute of the clinical conversation. Optimal care for people with chronic illnesses requires individuals to interact with health practitioners regarding their health concerns, but given these constraints, we know little about how patients strategise conversations with their care providers. This understanding may further our efforts to educate health practitioners and trainees to learn and practice patient-centred care. METHODS: A constructivist grounded theory approach with iterative data collection and analysis was used to explore the processes patients use to present and shape their stories for interactions with health practitioners. Twenty-one patients (n = 16 female; 5 male) representing a variety of chronic illnesses participated in semi-structured interviews. Using the constant comparative method of analysis, salient themes were ascertained. RESULTS: Patients engage in extensive strategic preparations for productive health encounters. From the data, we identified four related elements comprising patients' process of planning, preparing, and strategising for health encounters: deciding to go, organising to get airtime, rehearsing a game plan, and anticipating external forces. By focusing on the extensive preparatory work patients engage in, our study expands the dimensions of how we understand illness-related work. Assembling personal health information, gathering disease information and achieving equanimity represent the dimensions of this 'health interaction work'. CONCLUSION: The work patients engage in for health encounters is noteworthy yet often invisible. And work that is unseen may also be undervalued. Acknowledging, illuminating and valuing patients' preparatory work for health encounters add to how we understand patient-centred care, and this offers new targets for us to effectively teach and deliver it.

Contextual Competence: How residents develop competent performance in new settings.

INTRODUCTION: Medical education continues to diversify its settings. For postgraduate trainees, moving across diverse settings, especially community-based rotations, can be challenging personally and professionally. Competent performance is embedded in context; as a result, trainees who move to new contexts are challenged to use their knowledge, skills and experience to adjust. What trainees need to adapt to and what that requires of them are poorly understood. This research takes a capability approach to understand how trainees entering a new setting develop awareness of specific contextual changes that they need to navigate and learn from. METHODS: We used constructivist grounded theory with in-depth interviews. A total of 29 trainees and recent graduates from three internal medicine training programmes in Canada participated. All participants had completed at least one community-based rotation geographically far from their home training site. Interviews were recorded, transcribed and anonymised. The interview framework was adjusted several times following initial data analysis. RESULTS: Contextual competence results from trainees' ability to attend to five key stages. Participants had first to meet their physiological and practical needs, followed by developing a sense of belonging and legitimacy, which paved the way for a re-constitution of competence and appropriate autonomy. Trainee's attention to these stages of adaptation was facilitated by a process of continuously moving between using their knowledge and skill foundation and recognising where and when contextual differences required new learning and adaptations. DISCUSSION: An ability to recognise contextual change and adapt accordingly is part of Nussbaum and Sen's concept of capability development. We argue this key skill has not received the attention it deserves in current training models and in the support postgraduate trainees receive in practice. Recommendations include supporting residents in their capability development by debriefing their experiences of moving between settings and supporting clinical teachers as they actively coach residents through this process.

Approaching culture in medical education: Three perspectives.

BACKGROUND: The notion of culture is increasingly invoked in the medical education literature as a key influence on how educational strategies unfold, and culture change is frequently identified as a necessary precursor to progress. A meaningful perspective on what culture means is often missing from these discussions, however. Without a theoretically grounded notion of culture, calls for culture change are challenging to interpret and to act upon. OBJECTIVE: In this cross-cutting edge paper, we explore how culture has been defined and theorised using three lenses: the organisational perspective; the identity perspective, and the practice perspective. We consider what each perspective might offer to medical education researchers. RESULTS: Each of these perspectives draws on a range of disciplinary influences, and none represents a singular theory of culture. Broadly, the organisational perspective directs our attention to the shared assumptions and values that bind individuals within an organisation. It tends to view culture through a strategic lens; culture may be either a barrier to or a facilitator of the changes that are inevitably required of an organisation if it is to maintain its relevance. The identity perspective, particularly the notion of figured worlds, alerts us to the power of communal narratives to shape how individuals see themselves within particular cultural worlds. The practice perspective emphasises what actually occurs in practice, avoiding symbolic ideas about culture and shared values and instead privileging activity and human-material networks or arrangements. CONCLUSIONS: These diverse perspectives share a common thread- they shift our research gaze beyond the individual, allowing us instead to see how those individuals form organisations, inhabit cultural worlds and constitute practices. They afford substance and direction for explorations of culture, and thus offer the promise of a more nuanced understanding of some of medical education's most challenging problems.

Seeing but not believing: Insights into the intractability of failure to fail.

CONTEXT: Inadequate documentation of observed trainee incompetence persists despite research-informed solutions targeting this failure to fail phenomenon. Documentation could be impeded if assessment language is misaligned with how supervisors conceptualise incompetence. Because frameworks tend to itemise competence as well as being vague about incompetence, assessment design may be improved by better understanding and describing of how supervisors experience being confronted with a potentially incompetent trainee. METHODS: Following constructivist grounded theory methodology, analysis using a constant comparison approach was iterative and informed data collection. We interviewed 22 physicians about their experiences supervising trainees who demonstrate incompetence; we quickly found that they bristled at the term 'incompetence,' so we began to use 'underperformance' in its place. RESULTS: Physicians began with a belief and an expectation: all trainees should be capable of learning and progressing by applying what they learn to subsequent clinical experiences. Underperformance was therefore unexpected and evoked disbelief in supervisors, who sought alternate explanations for the surprising evidence. Supervisors conceptualised underperformance as: an inability to engage with learning due to illness, a life event or learning disorders, so that progression was stalled, or an unwillingness to engage with learning due to lack of interest, insight or humility. CONCLUSION: Physicians conceptualise underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure to fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance. The findings offer further insight and possible new solutions to address under-documentation of underperformance.

Assessment, feedback and the alchemy of learning.

CONTEXT: Models of sound assessment practices increasingly emphasise assessment's formative role. As a result, assessment must not only support sound judgements about learner competence, but also generate meaningful feedback to guide learning. Reconciling the tension between assessment's focus on judgement and decision making and feedback's focus on growth and development represents a critical challenge for researchers and educators. METHODS: We synthesise the literature related to this tension, framed around four trends in education research: (i) shifting perspectives on assessment; (ii) shifting perspectives on feedback; (iii) increasing attention on learners' perceptions of assessment and feedback, and (iv) increasing attention on the influence of culture on assessment and feedback. We describe factors that produce and sustain this tension. RESULTS: The lines between assessment and feedback frequently blur in medical education. Models of programmatic assessment deliberately use the same data for both purposes: low-stakes individual data points are used formatively, but then are added together to support summative judgements. However, the translation of theory to practice is not straightforward. Efforts to embed meaningful feedback in programmes of learning face a multitude of threats. Learners may perceive assessment with formative intent as summative, restricting their engagement with it as feedback, and thus diminishing its learning value. A learning culture focused on assessment may limit learners' sense of safety to explore, to experiment, and sometimes to fail. CONCLUSIONS: Successfully blending assessment and feedback demands clarity of purpose, support for learners, and a system and organisational commitment to a culture of improvement rather than a culture of performance.

Where philosophy meets culture: exploring how coaches conceptualise their roles.

CONTEXT: Although conceptually attractive, coaching in medicine remains ill-defined, with little examination of the transferability of coaching principles from other fields. Here we explore how coaching is enacted both within and outside of medicine; we aim to understand both the elements required for coaching to be useful and the factors that may influence its translation to the medical education context. METHODS: In this constructivist grounded theory study, we interviewed 24 individuals across three groups: physicians who consider themselves coaches in clinical learning settings (n = 8), physicians with experience as sports, arts or business coaches (n = 10), and sports coaches without medical backgrounds (n = 6). Data collection and analysis were conducted iteratively using constant comparison to identify themes and explore their relationships. RESULTS: We identified a shared philosophy of coaching, comprising three core elements that our participants endorsed regardless of the coaching context: (i) mutual engagement, with a shared orientation towards growth and development; (ii) ongoing reflection involving both learners and coaches, and (iii) an embrace of failure as a catalyst for learning. Enacting these features appeared to be influenced by culture, which affected how coaching was defined and developed, how the coaching role was positioned within the learning context, and how comfortably vulnerability could be expressed. Participants struggled to clearly define the coaching role in medicine, instead acknowledging that the lines between educational roles were often blurred. Further, the embrace of failure appeared challenging in medicine, where showing vulnerability was perceived as difficult for both learners and teachers. CONCLUSIONS: Medical education's embrace of coaching should be informed by an understanding of both coach and learner behaviours that need to be encouraged and trained, and the cultural and organisational supports that are required to foster success.

Some assembly required: tracing the interpretative work of Clinical Competency Committees.

OBJECTIVES: This qualitative study describes the social processes of evidence interpretation employed by Clinical Competency Committees (CCCs), explicating how they interpret, grapple with and weigh assessment data. METHODS: Over 8 months, two researchers observed 10 CCC meetings across four postgraduate programmes at a Canadian medical school, spanning over 25 hours and 100 individual decisions. After each CCC meeting, a semi-structured interview was conducted with one member. Following constructivist grounded theory methodology, data collection and inductive analysis were conducted iteratively. RESULTS: Members of the CCCs held an assumption that they would be presented with high-quality assessment data that would enable them to make systematic and transparent decisions. This assumption was frequently challenged by the discovery of what we have termed 'problematic evidence' (evidence that CCC members struggled to meaningful interpret) within the catalogue of learner data. When CCCs were confronted with 'problematic evidence', they engaged in lengthy, effortful discussions aided by contextual data in order to make meaning of the evidence in question. This process of effortful discussion enabled CCCs to arrive at progression decisions that were informed by, rather than ignored, problematic evidence. CONCLUSIONS: Small groups involved in the review of trainee assessment data should be prepared to encounter evidence that is uncertain, absent, incomplete, or otherwise difficult to interpret, and should openly discuss strategies for addressing these challenges. The answer to the problem of effortful processes of data interpretation and problematic evidence is not as simple as generating more data with strong psychometric properties. Rather, it involves grappling with the discrepancies between our interpretive frameworks and the inescapably subjective nature of assessment data and judgement.

Exploring researchers' perspectives on authorship decision making.

CONTEXT: Authorship has major implications for researchers' careers. Hence, journals require researchers to meet formal authorship criteria. However, researchers frequently admit to violating these criteria, which suggests that authorship is a complex issue. This study aims to unpack the complexities inherent in researchers' conceptualisations of questionable authorship practices and to identify factors that make researchers vulnerable to engaging in such practices. METHODS: A total of 26 North American medical education researchers at a range of career stages were interviewed. Participants were asked to respond to two vignettes, of which one portrayed honorary authorship and the other described an author order scenario, and then to describe related authorship experiences. Data were analysed using thematic analysis. RESULTS: Participants conceptualised questionable authorship practices in various ways and articulated several ethically grey areas. Personal and situational factors were identified, including hierarchy, resource dependence, institutional culture and gender; these contributed to participants' vulnerability to and involvement in questionable authorship practices. Participants described negative instances of questionable authorship practices as well as situations in which these practices were used for virtuous purposes. Participants rationalised engagement in questionable authorship practices by suggesting that, although technically violating authorship criteria, such practices could be reasonable when they seemed to benefit science. CONCLUSIONS: Authorship guidelines portray authorship decisions as being black and white, effectively sidestepping key dimensions that create ethical shades of grey. These findings show that researchers generally recognise these shades of grey and in some cases acknowledge having bent the rules themselves. Sometimes their flexibility is driven by benevolent aims aligned with their own values or prevailing norms such as inclusivity. At other times participation in these practices is framed not as a choice, but rather as a consequence of researchers' vulnerability to individual or system factors beyond their control. Taken together, these findings provide insights to help researchers and institutions move beyond recognition of the challenges of authorship and contribute to the development of informed, evidence-based solutions.

Considering the interdependence of clinical performance: implications for assessment and entrustment.

INTRODUCTION: Our ability to assess independent trainee performance is a key element of competency-based medical education (CBME). In workplace-based clinical settings, however, the performance of a trainee can be deeply entangled with others on the team. This presents a fundamental challenge, given the need to assess and entrust trainees based on the evolution of their independent clinical performance. The purpose of this study, therefore, was to understand what faculty members and senior postgraduate trainees believe constitutes independent performance in a variety of clinical specialty contexts. METHODS: Following constructivist grounded theory, and using both purposive and theoretical sampling, we conducted individual interviews with 11 clinical teaching faculty members and 10 senior trainees (postgraduate year 4/5) across 12 postgraduate specialties. Constant comparative inductive analysis was conducted. Return of findings was also carried out using one-to-one sessions with key informants and public presentations. RESULTS: Although some independent performances were described, participants spoke mostly about the exceptions to and disclaimers about these, elaborating their sense of the interdependence of trainee performances. Our analysis of these interdependence patterns identified multiple configurations of coupling, with the dominant being coupling of trainee and supervisor performance. We consider how the concept of coupling could advance workplace-based assessment efforts by supporting models that account for the collective dimensions of clinical performance. CONCLUSION: These findings call into question the assumption of independent performance, and offer an important step toward measuring coupled performance. An understanding of coupling can help both to better distinguish independent and interdependent performances, and to consider revising workplace-based assessment approaches for CBME.

Patient- and family-centered care: a qualitative exploration of oncologist perspectives.

PURPOSE: Increasingly, patient- and family-centered care (PFCC) is recognized as a valuable component of healthcare reform with rich opportunities for improvement within oncology. Shifting toward PFCC requires physician buy-in; however, research examining their perspectives on PFCC is lacking. We sought to explore oncologists' perspectives on PFCC to identify factors that influence their ability to practice PFCC. METHODS: We conducted semi-structured interviews with 18 oncologists (8 radiation, 4 medical, 4 surgical, 2 hematologist-oncologists) at a single Canadian academic cancer institution. Interview data were analyzed using thematic analysis and principles drawn from grounded theory. Subsequently, focus groups consisting of the interviewed participants were facilitated to confirm and elaborate on our findings. Constant comparisons were used to identify recurring themes. RESULTS: Three dominant themes emerged. First, physicians displayed cautious engagement in their approach to PFCC. Collectively, participants understood the general principles of PFCC. However, there was a limited understanding of the value, implications, and motivation for improving PFCC which may create reluctance with physician buy-in. Second, both individual and system barriers to practicing PFCC were identified. A lack of physician acknowledgement and engagement and competing responsibilities emerged as provider-level challenges. System barriers included impaired clinic workflow, physical infrastructure constraints, and delays in access to care. Third, physicians were able to identify existing and potential PFCC behaviors that were feasible within existing system constraints. CONCLUSIONS: Advancing PFCC will require continued physician education regarding the value of PFCC, acknowledgement and preservation of effective patient- and family-centered strategies, and creative solutions to address the system constraints to delivering PFCC.

Qualitative and quantitative feedback in the context of competency-based education.

Research indicates the importance and usefulness of feedback, yet with the shift of medical curricula toward competencies, feedback is not well understood in this context. This paper attempts to identify how feedback fits within a competency-based curriculum. After careful consideration of the literature, the following conclusions are drawn: (1) Because feedback is predicated on assessment, the assessment should be designed to optimize and prevent inaccuracies in feedback; (2) Giving qualitative feedback in the form of a conversation would lend credibility to the feedback, address emotional obstacles and create a context in which feedback is comfortable; (3) Quantitative feedback in the form of individualized data could fulfill the demand for more feedback, help students devise strategies on how to improve, allow students to compare themselves to their peers, recognizing that big data have limitations; and (4) Faculty development needs to incorporate and promote cultural and systems changes with regard to feedback. A better understanding of the role of feedback in competency-based education could result in more efficient learning for students.

Evolving Motivations: Patients' and Caregivers' Perceptions About Seeking Myotonic Dystrophy (DM1) and Huntington's Disease Care.

Patient-centered care provision is challenging under ideal circumstances; myotonic dystrophy (DM1) and Huntington's disease (HD) are examples of chronic, progressive health conditions that may challenge its limits. If we can understand how care unfolds in these conditions, health care providers may be better equipped to address patients' needs. Constructivist grounded theory informed data collection and analysis. Fourteen patients with DM1 or HD, and 10 caregivers participated in semistructured interviews. Constant comparative analysis was used to identify themes. Participants attended clinic to seek expert information and social support. Medical management, altruism, and support provided the motivation. However, motivations evolved, with clinic becoming more important for caregivers as patients deteriorated. Clinic was conceptualized as a "safe space" to actively participate in health care and research. In the absence of disease-halting or curative treatments, participants perceived that they derived a therapeutic benefit from seeking care and from engaging in education and advocacy.