Relinquishing control? Supervisor co-regulation may disrupt students' self-regulated learning during simulation-based training.

When uncertain, medical trainees often seek to co-regulate their learning with supervisors and peers. Evidence suggests they may enact self-regulated learning (SRL) strategies differently when engaged in self- versus co-regulated learning (Co-RL). We compared the impacts of SRL and Co-RL on trainees' acquisition, retention, and preparation for future learning (PFL) of cardiac auscultation skills during simulation-based training. In our two-arm, prospective, non-inferiority trial, we randomly assigned first- and second-year medical students to the SRL (N = 16) or Co-RL conditions (N = 16). Across two learning sessions separated by two-weeks, participants practiced and were assessed in diagnosing simulated cardiac murmurs. We examined diagnostic accuracy and learning trace data across sessions, and conducted semi-structured interviews to explore participants' understandings of their underlying choices and learning strategies. SRL participants' outcomes were non-inferior to Co-RL participants on the immediate post-test and retention test, but not on the PFL assessment (i.e., inconclusive). Analyzing interview transcripts (N = 31) generated three themes: perceived utility of initial learning supports for future learning; SRL strategies and sequencing of murmurs; and perceived control over learning across sessions. Co-RL participants regularly described relinquishing control of learning to supervisors and regaining it when on their own. For some trainees, Co-RL seemed to interfere with their situated and future SRL. We posit that transient clinical training sessions, typical in simulation-based and workplace-based settings, may not allow the ideal processes of Co-RL to unfold between supervisor and trainee. Future research must examine how supervisors and trainees can share accountability to develop the shared mental models that underlie effective Co-RL.

Dual purposes by design: exploring alignment between residents' and academic advisors' documents in a longitudinal program.

Longitudinal academic advising (AA) and coaching programs are increasingly implemented in competency based medical education (CBME) to help residents reflect and act on the voluminous assessment data they receive. Documents created by residents for purposes of reflection are often used for a second, summative purpose-to help competence committees make decisions-which may be problematic. Using inductive, thematic analysis we analyzed written comments generated by 21 resident-AA dyads in one large internal medicine program who met over a 2 year period to determine what residents write when asked to reflect, how this aligns with what the AAs report, and what changes occur over time (total 109 resident self-reflections and 105 AA reports). Residents commented more on their developing autonomy, progress and improvement than AAs, who commented far more on performance measures. Over time, residents' writing shifted away from intrinsic roles, patient care and improvement towards what AAs focused on, including getting EPAs (entrustable professional activities), studying and exams. For EPAs, the emphasis was on getting sufficient numbers rather than reflecting on what residents were learning. Our findings challenge the practice of dual-purposing documents, by questioning the blurring of formative and summative intent, the structure of forms and their multiple conflicting purposes, and assumptions about the advising relationship over time. Our study suggests a need to re-evaluate how reflective documents are used in CBME programs. Further research should explore whether and how documentation can best be used to support resident growth and development.

Exploring mentorship in surgery: An interview study on how people stick together.

OBJECTIVE: The objective is to explore the processes contributing to how and why mentors and mentees initiate, maintain and grow in their mentorship relationships in surgery. BACKGROUND: To explore the processes contributing to how and why mentors and mentees initiate, maintain and grow their mentorship relationships in surgery. Evidence suggests that mentorship has a positive impact on physicians' success. Consequently, mentorship programmes have been incorporated into many medicine environments, albeit with variable success. METHODS: We designed an interview-based study using a constructivist grounded theory approach to explore the dynamics of mentorship between junior and experienced surgeons. Recruited mentees were asked to nominate a senior surgeon they identified as a mentor. Both mentee and mentors were then interviewed separately. Transcripts were analysed using constant comparison to a create a final coding framework and to generate themes. RESULTS: We interviewed nine faculty mentors and 10 junior faculty mentees. Our analysis identified key themes describing how to initiate, maintain and grow a mentorship relationship. Mentorship starts with ensuring a 'good fit', persists through satisfying a reciprocal loop with timely communication and deepens the relationship through cycles of mutual investment, learning, and success. Participants also discussed how to navigate through tensions to avoid relationship breakdown, balancing formality and friendship, knowing when to transition a relationship to a new dynamic and finding areas of realistic contribution. CONCLUSIONS: We found that successful mentorship relationships are viewed as dynamic and thus require active investment and shared responsibility between mentees and mentors. Our results also emphasise the value of co-regulation in the relationship, where cycles of mutual investment can contribute to mutual learning and growth.

The fundamentals of Artificial Intelligence in medical education research: AMEE Guide No. 156.

The use of Artificial Intelligence (AI) in medical education has the potential to facilitate complicated tasks and improve efficiency. For example, AI could help automate assessment of written responses, or provide feedback on medical image interpretations with excellent reliability. While applications of AI in learning, instruction, and assessment are growing, further exploration is still required. There exist few conceptual or methodological guides for medical educators wishing to evaluate or engage in AI research. In this guide, we aim to: 1) describe practical considerations involved in reading and conducting studies in medical education using AI, 2) define basic terminology and 3) identify which medical education problems and data are ideally-suited for using AI.

Mastery versus invention learning: impacts on future learning of simulated procedural skills.

BACKGROUND: Invention and mastery learning approaches differ in their foundational educational paradigms, proposed mechanisms of learning, and potential impacts on learning outcomes. They also differ in their resource requirements. We explored the relative effects of 'invent and problem-solve, followed by instruction' (PS-I) learning compared to mastery learning (i.e., standards-based training) on immediate post-test and Preparation for Future Learning (PFL) assessments. PFL assessments measure learners' capacity to use their existing knowledge and strategies to learn about and solve novel problems. METHODS: In this non-inferiority trial, pre-clerkship medical students were randomized to either PS-I, Mastery Learning (ML), or instruction then practice (CON) during simulation-based training of infant lumbar puncture (LP). After a 2-week delay, participants returned to learn and complete a PFL assessment of simulated Knee Arthrocentesis. Two independent raters assessed performances with a 5-point global rating scale. RESULTS: Based on our non-inferiority margin, analyses showed that for both the immediate post-test and the PFL assessment, the PS-I condition resulted in non-inferior outcomes relative to the ML condition. Results for the CON condition were mixed with respect to non-inferiority compared to either PS-I or ML. CONCLUSIONS: We suggest cautiously that the PS-I approach was not inferior to the ML approach, based on skill acquisition and PFL assessment outcomes. With ML anecdotally and empirically requiring more time, greater faculty involvement, and higher costs, our findings question the preference ML has received relative to other instructional designs, especially in the healthcare simulation community. We encourage researchers to study the educational and resource impacts of instructional designs using non-inferiority designs.

Re-examining the integration of routine and adaptive expertise: there is no such thing as routine from a motor control perspective.

The study of adaptive expertise in health professions education has focused almost exclusively on cognitive skills, largely ignoring the processes of adaptation in the performance of precision technical skills. We present a focused review of literature to argue that repetitive practice is much less repetitive than often perceived. Our main thesis is that all skilled movement reflects components of adaptive expertise. Through an overview of perspectives from the field of motor control and learning, we emphasize the interplay between the inherent noisiness of the human motor architecture and the stability of motor skill performances. Ultimately, we challenge the very idea of routine. Our goal is threefold: to reconcile common misconceptions about the rote nature of routine precision skill performance, to offer educators principles to enhance adaptive expertise as an outcome of precision skill training, and to expand the conversation between 'routine' and 'adaptive' forms of expertise in health professions education.

Toward 'seeing' critically: a Bayesian analysis of the impacts of a critical pedagogy.

Critical reflection supports enactment of the social roles of care, like collaboration and advocacy. We require evidence that links critical teaching approaches to future critically reflective practice. We thus asked: does a theory-informed approach to teaching critical reflection influence what learners talk about (i.e. topics of discussion) and how they talk (i.e. whether they talk in critically reflective ways) during subsequent learning experiences? Pre-clinical students (n = 75) were randomized into control and intervention conditions (8 groups each, of up to 5 interprofessional students). Participants completed an online Social Determinants of Health (SDoH) module, followed by either: a SDoH discussion (control) or critically reflective dialogue (intervention). Participants then experienced a common learning session (homecare curriculum and debrief) as outcome assessment, and another similar session one-week later. Blinded coders coded transcripts for what (topics) was said and how (critically reflective or not). We constructed Bayesian regression models for the probability of meaning units (unique utterances) being coded as particular what codes and as critically reflective or not (how). Groups exposed to the intervention were more likely, in a subsequent learning experience, to talk in a critically reflective manner (how) (0.096 [0.04, 0.15]) about similar content (no meaningful differences in what was said). This difference waned at one-week follow up. We showed experimentally that a particular critical pedagogical approach can make learners' subsequent talk, ways of seeing, more critically reflective even when talking about similar topics. This study offers the field important new options for studying historically challenging-to-evaluate impacts and supports theoretical assertions about the potential of critical pedagogies.

Evaluation of an advanced critical care echocardiography program: a mixed methods study.

PURPOSE: Limited data exist on advanced critical care echocardiography (CCE) training programs for intensivists. We sought to describe a longitudinal echocardiography program and investigate the effect of distributed conditional supervision vs predefined en-bloc supervision, as well as the effect of an optional echocardiography laboratory rotation, on learners' engagement. METHODS: In this mixed methods study, we enrolled critical care fellows and faculty from five University of Toronto-affiliated intensive care units (ICU) between July 2015 and July 2018 in an advanced training program, comprising theoretical lectures and practical sessions. After the first year, the program was modified with changes to supervision model and inclusion of a rotation in the echo laboratory. We conducted semistructured interviews and investigated the effects of curricular changes on progress toward portfolio completion (150 transthoracic echocardiograms) using a Bayesian framework. RESULTS: Sixty-five learners were enrolled and 18 were interviewed. Four (9%) learners completed the portfolio. Learners reported lack of time and supervision, and skill complexity as the main barriers to practicing independently. Conditional supervision was associated with a higher rate of submitting unsupervised echocardiograms than unconditional supervision (rate ratio, 1.11, 95% credible interval, 1.08 to 1.14). After rotation in the echocardiography laboratory, submission of unsupervised echocardiograms decreased. CONCLUSION: Trainees perceived lack of time and limited access to supervision as major barriers to course completion. Nevertheless, successful portfolio completion was related to factors other than protected time in the echocardiography laboratory or unconditional direct supervision in ICU. Further research is needed to better understand the factors promoting success of CCE training programs.

RéSUMé: OBJECTIF: Il n'existe que peu de données sur les programmes de formation avancés en échocardiographie pour les soins intensifs (écho-USI) destinés aux intensivistes. Nous avons cherché à décrire un programme longitudinal d'échocardiographie et à étudier l'effet d'une supervision conditionnelle distribuée vs une supervision prédéfinie en bloc, ainsi que l'effet d'une rotation facultative en laboratoire d'échocardiographie, sur le niveau d'implication des apprenants. MéTHODE: Dans cette étude à méthodes mixtes, nous avons recruté des fellows en soins intensifs et des professeurs de cinq unités de soins intensifs (USI) affiliées à l'Université de Toronto entre juillet 2015 et juillet 2018 pour participer à un programme de formation avancée comprenant des conférences théoriques et des séances pratiques. Après la première année, le programme a été modifié en apportant des changements au modèle de supervision et en incluant une rotation dans le laboratoire d'écho. Nous avons mené des entretiens semi-structurés et étudié les effets des changements du programme d'études sur les progrès vers la réussite de la formation (150 échocardiogrammes transthoraciques) en utilisant un cadre bayésien. RéSULTATS: Soixante-cinq apprenants étaient inscrits et 18 ont été interviewés. Quatre (9 %) apprenants ont complété la formation. Les apprenants ont signalé que le manque de temps et de supervision ainsi que la complexité des compétences constituaient les principaux obstacles à une pratique autonome. La supervision conditionnelle était associée à un taux plus élevé de soumission d'échocardiogrammes non supervisés que la supervision inconditionnelle (ratio de taux, 1,11, intervalle crédible à 95 %, 1,08 à 1,14). Après la rotation dans le laboratoire d'échocardiographie, la soumission d'échocardiogrammes non supervisés a diminué. CONCLUSION: Les stagiaires ont perçu le manque de temps et l'accès limité à la supervision comme des obstacles majeurs à la réussite de la formation. Néanmoins, l'achèvement du cours était lié à des facteurs autres que le temps protégé au laboratoire d'échocardiographie ou la supervision directe inconditionnelle aux soins intensifs. D'autres recherches sont nécessaires pour mieux comprendre les facteurs favorisant le succès des programmes de formation en écho-USI.

Applying activity theory to undergraduate medical curriculum reform: Lessons in contradictions from multiple stakeholders' perspectives.

PURPOSE: Medical school curricula require regular updating. We adopted an activity theory lens to conduct a holistic, multiple stakeholder-informed analysis of curricular reform, aiming to understand how the social relations between groups contribute to unanticipated tensions and outcomes. METHODS: A research assistant conducted semi-structured interviews with purposively sampled (N = 19) administrative staff, faculty course leads, faculty tutors, curriculum developers, change leaders and student leaders. The team applied a framework analysis to guide within and between stakeholder comparisons. RESULTS: Participants reported unique (N = 21) and cross-cutting (N = 17) contradictions underscoring emerging drivers of current and potential change. Unique contradictions raised by 1-2 groups represented seeds of change that had the potential to spread across all groups. By contrast, two general types of cross-cutting contradictions arose when one group had a dominant, confirming voice or two or more groups had contrasting perspectives. CONCLUSIONS: While finding contradictions was expected, our analysis profiled their nature and some of the specific tensions they raised across and within stakeholder groups. The activity theory lens provided an accessible way to unravel curricular reform into manageable units of analysis. Systematically identifying contradictions arising from curricular reform will help stakeholders collaborate with a shared purpose toward positive, sustained change.

Development of the Diabetic Wound Assessment Learning Tool (DiWALT) and validity evidence.

OBJECTIVE: Diabetic foot wounds account for up to one-third of diabetes-related health care expenditure and are the greatest cause of extremity amputation in Canada. Physicians encounter patients with such wounds in all specialties, particularly as generalists in medical wards and emergency departments. However, there is a dearth of literature on the optimal way to teach and to assess the management of these patients. Given the importance of assessment for learning in the shift toward competency-based medical education, we aimed to develop an assessment tool and to build validity evidence for its use in this context. METHODS: A consensus process involving nine Canadian experts in diabetic wound management was used to develop the Diabetic Wound Assessment Learning Tool (DiWALT) items and two 10-minute simulation-based testing scenarios. The simulators used were modified from commercially available models to serve the testing scenarios. Validity evidence for the DiWALT was subsequently evaluated by assessing 24 physician participants' performance during the two scenarios. All participants were novices (<50 cases managed). Two assessors independently rated participants using the DiWALT. Evidence was organized using Kane's validity framework and included Cronbach α for interitem consistency as well as test-retest and inter-rater reliability using the intra-class correlation coefficient (ICC). RESULTS: Cronbach α was 0.92, implying high internal consistency. Test-retest reliability was also excellent with ICC of 0.89 (confidence interval [CI], 0.76-0.95) for single measures and ICC of 0.94 (CI, 0.86-0.98) for average measures. Inter-rater reliability was fair for single measures with ICC of 0.68 (CI, 0.65-0.71) and good for average measures with ICC of 0.81 (CI, 0.79-0.83). CONCLUSIONS: These results demonstrate that the DiWALT consistently and reliably evaluates competence in diabetic wound management during simulated cases using a small, homogeneous sample of physicians. Further work is necessary to quantify sources of error in the assessment scores, to establish validity evidence when it is used to assess larger and more heterogeneous participants, and to identify how well the DiWALT differentiates between different experience levels.

The myth of ivory tower versus practice-oriented research: A systematic review of randomised studies in medical education.

CONTEXT: A long-standing myth in medical education research is a divide between two different poles: research aiming to advance theory with little focus on practical applications ('ivory tower' research) and practically oriented research aiming to serve educators and decision-makers with little focus on advancing theory ('in-the-trenches' practice). We explored this myth in a sample of randomised medical education studies using Stokes' four-quadrant framework for the classification of research perspective. METHODS: We searched MEDLINE, Embase, CINAHL, PsychINFO, ERIC, Web of Science and Scopus for studies in medical education using a randomised design that were published between 1 January 2018 and 31 December 2018. We used Stokes' four-quadrant framework to categorise the studies according to their use of theory, concepts and their justification for practical use. We compared medical education research published in medical education journals and clinical journals. RESULTS: A total of 150 randomised studies were included in the analysis. The largest segment of studies (46.7%) was categorised as use-inspired basic research (Pasteur's Quadrant), closely followed by pure applied research (40.7%, Edison's Quadrant). Only a few studies were categorised as aiming to advance knowledge with no thought for practical educational application (2.0%, Bohr's Quadrant). The proportion of studies that included educational concepts and theory differed according to publication in clinical journals or medical education journals: 40.5% vs 71.8%, respectively, P < .001. There were no differences between journals with regard to the proportion of studies that included a practical educational or clinical rationale (P = .99). CONCLUSION: In a large sample of studies using randomised designs, we found no evidence to support the myth that medical education research divides between two singular poles represented by 'ivory tower research' and 'in-the-trenches practice'. We did confirm prevailing assumptions regarding an emphasis on non-theoretical medical education research in clinical journals.

Implicit and inferred: on the philosophical positions informing assessment science.

Assessment practices have been increasingly informed by a range of philosophical positions. While generally beneficial, the addition of options can lead to misalignment in the philosophical assumptions associated with different features of assessment (e.g., the nature of constructs and competence, ways of assessing, validation approaches). Such incompatibility can threaten the quality and defensibility of researchers' claims, especially when left implicit. We investigated how authors state and use their philosophical positions when designing and reporting on performance-based assessments (PBA) of intrinsic roles, as well as the (in)compatibility of assumptions across assessment features. Using a representative sample of studies examining PBA of intrinsic roles, we used qualitative content analysis to extract data on how authors enacted their philosophical positions across three key assessment features: (1) construct conceptualizations, (2) assessment activities, and (3) validation methods. We also examined patterns in philosophical positioning across features and studies. In reviewing 32 papers from established peer-reviewed journals, we found (a) authors rarely reported their philosophical positions, meaning underlying assumptions could only be inferred; (b) authors approached features of assessment in variable ways that could be informed by or associated with different philosophical assumptions; (c) we experienced uncertainty in determining (in)compatibility of philosophical assumptions across features. Authors' philosophical positions were often vague or absent in the selected contemporary assessment literature. Leaving such details implicit may lead to misinterpretation by knowledge users wishing to implement, build on, or evaluate the work. As such, assessing claims, quality and defensibility, may increasingly depend more on who is interpreting, rather than what is being interpreted.

Resident competencies before and after short intensive care unit rotations: a multicentre pilot observational study.

PURPOSE: Residency programs need to understand the competencies developed by residents during an intensive care unit (ICU) rotation, so that curricula and assessments maximize residents' learning. The primary study objective was to evaluate the feasibility for training programs and acceptability by residents of conducting a multi-competency assessment during a four-week ICU rotation. METHODS: We conducted a prospective, multicentre observational pilot study in three ICUs. During weeks 1 and 4 of an ICU rotation, we conducted repeated standardized assessments of non-critical care specialty residents' competencies in cognitive reasoning (script concordance test [SCT]), procedural skills (objective structured assessment of technical skills [OSATS]-global rating scale], and communication skills through a written test, two procedural simulations, and a simulated encounter with a "family member". The feasibility outcomes included program costs, the proportion of enrolled residents able to complete at least one three-station assessment during their four-week ICU rotation, and acceptability of the assessment for the trainees. RESULTS: We enrolled 63 (69%) of 91 eligible residents, with 58 (92%) completing at least one assessment. The total cost to conduct 90 assessments was CAD 33,800. The majority of participants agreed that the assessment was fair and that it measured important clinical abilities. For the 32 residents who completed two assessments, the mean (standard deviation) cognitive reasoning and procedural skill scores increased between weeks 1 and 4 [SCT difference, 3.1 (6.5), P = 0.01; OSATS difference for bag-mask ventilation and central line insertion, 0.4 (0.5) and 0.6 (0.8), respectively; both P ≤ 0.001]. Nevertheless, the communication scores did not change significantly. CONCLUSIONS: A monthly multi-competency assessment for specialty residents rotating in the ICU is likely feasible for most programs with appropriate resources, and generally acceptable for residents. Specialty residents' cognitive reasoning and procedural skills may improve during a four-week ICU rotation, whereas communication skills may not.

RéSUMé: OBJECTIF: Afin que les programmes de formation et les évaluations maximisent les apprentissages des résidents, les programmes de résidence doivent comprendre quelles compétences sont développées par les résidents pendant un stage à l'unité de soins intensifs (USI). L'objectif principal de cette étude était d'évaluer la faisabilité pour les programmes de formation et l'acceptabilité par les résidents de réaliser une évaluation multi-compétences pendant un stage de quatre semaines à l'USI. MéTHODE: Nous avons réalisé une étude pilote observationnelle prospective multicentrique dans trois USI. Pendant les semaines 1 et 4 du stage à l'USI, nous avons mené des évaluations standardisées répétées des compétences des résidents non inscrits dans une spécialisation en soins intensifs en matière de raisonnement cognitif (test de concordance de script [SCT]), d'habiletés procédurales (évaluation objective structurée des compétences techniques [OSATS] - échelle d'évaluation globale), et d'habiletés de communication via un examen écrit, deux simulations d'intervention, et une rencontre simulée avec un « membre de la famille ¼. Les critères de faisabilité comprenaient les coûts du programme d'évaluation, la proportion de résidents inscrits capables de compléter au moins une évaluation en trois stations au cours de leur stage de quatre semaines à l'USI, et l'acceptabilité de l'évaluation par les résidents. RéSULTATS: Nous avons recruté 63 (69 %) des 91 résidents éligibles, et 58 (92 %) ont complété au moins une évaluation. Le coût total pour réaliser 90 évaluations était de 33 800 CAD. La majorité des participants étaient d'accord que l'évaluation était équitable et qu'elle mesurait d'importantes habiletés cliniques. Chez les 32 résidents ayant complété deux évaluations, les scores moyens (écart type) en matière de raisonnement cognitif et d'habiletés techniques ont augmenté entre les semaines 1 et 4 : différence au SCT, 3,1 (6,5), P = 0,0; différence à l'OSATS pour la ventilation au masque et l'installation d'une voie centrale, 0,4 (0,5) et 0,6 (0,8), respectivement; tous deux P ≤ 0,001. Toutefois, les scores en matière de communication n'ont pas changé de manière significative. CONCLUSION: Une évaluation multi-compétences mensuelle des résidents en spécialisation faisant un stage à l'USI est probablement réalisable dans la plupart des programmes disposant des ressources nécessaires, et elle est généralement acceptable pour les résidents. Le raisonnement cognitif et les habiletés techniques des résidents pourraient s'améliorer pendant un stage de quatre semaines à l'USI, alors que leurs compétences de communication pourraient demeurer inchangées.

How supervision and educational supports impact medical students' preparation for future learning of endotracheal intubation skills: a non-inferiority experimental trial.

BACKGROUND: Professional education cannot keep pace with the rapid advancements of knowledge in today's society. But it can develop professionals who can. 'Preparation for future learning' (PFL) has been conceptualized as a form of transfer whereby learners use their previous knowledge to learn about and adaptively solve new problems. Improved PFL outcomes have been linked to instructional approaches targeting learning mechanisms similar to those associated with successful self-regulated learning (SRL). We expected training that includes evidence-based SRL-supports would be non-inferior to training with direct supervision using the outcomes of a 'near transfer' test, and a PFL assessment of simulated endotracheal intubation skills. METHOD: This study took place at the University of Toronto from October 2014 to August 2015. We randomized medical students and residents (n = 54) into three groups: Unsupervised, Supported; Supervised, Supported; and Unsupervised, Unsupported. Two raters scored participants' test performances using a Global Rating Scale with strong validity evidence. We analyzed participants' near transfer and PFL outcomes using two separate mixed effects ANCOVAs. RESULTS: For the Unsupervised, Supported group versus the Supervised, Supported group, we found that the difference in mean scores was 0.20, with a 95% Confidence Interval (CI) of - 0.17 to 0.57, on the near transfer test, and was 0.09, with a 95% CI of - 0.28 to 0.46, on the PFL assessment. Neither mean score nor their 95% CIs exceeded the non-inferiority margin of 0.60 units. Compared to the two Supported groups, the Unsupervised, Unsupported group was non-inferior on the near transfer test (differences in mean scores were 0.02 and - 0.22). On the PFL assessment, however, the differences in mean scores were 0.38 and 0.29, and both 95% CIs crossed the non-inferiority margin. CONCLUSIONS: Training with SRL-supports was non-inferior to training with a supervisor. Both interventions appeared to impact PFL assessment outcomes positively, yet inconclusively when compared to the Unsupervised and Unsupported group, By contrast, the Unsupervised, Supported group did not score well on the near transfer test. Based on the observed sensitivity of the PFL assessment, we recommend researchers continue to study how such assessments may measure learners' SRL outcomes  during structured learning experiences.

Resident learning trajectories in the workplace: A self-regulated learning analysis.

CONTEXT: Research in workplace learning has emphasised trainees' active role in their education. By focusing on how trainees fine-tune their strategic learning, theories of self-regulated learning (SRL) offer a unique lens to study workplace learning. To date, studies of SRL in the workplace tend to focus on listing the factors affecting learning, rather than on the specific mechanisms trainees use to regulate their goal-directed activities. To inform the design of workplace learning interventions that better support SRL, we asked: How do residents navigate their exposure to and experience performing invasive procedures in intensive care units? METHODS: In two academic hospitals, we conducted post-call debriefs with residents coming off shift and later sought their elaborated perspectives via semi-structured interviews. We used a constant comparative methodology to analyse the data, to iteratively refine data collection, and to inform abductive coding of the data, using SRL principles as sensitising concepts. RESULTS: We completed 29 debriefs and nine interviews with 24 trainees. Participants described specific mechanisms: identifying, creating, avoiding, missing and competing for opportunities to perform invasive procedures. While using these mechanisms to engage with procedures (or not), participants reported: distinguishing trajectories (i.e. becoming attuned to task-relevant factors), navigating trajectories (i.e. creating and interacting with opportunities to perform procedures), and co-constructing trajectories with their peers, supervisors and interprofessional team members. CONCLUSIONS: We identified specific SRL mechanisms trainees used to distinguish and navigate possible learning trajectories. We also confirmed previous findings, including that trainees become attuned to interactions between personal, behavioural and environmental factors (SRL theory), and that their resulting learning behaviours are constrained and guided by interactions with peers, supervisors and colleagues (workplace learning theory). Making learning trajectories explicit for clinician teachers may help them support trainees in prioritising certain trajectories, in progressing along each trajectory, and in co-constructing their plans for navigating them.

Why Content and Cognition Matter: Integrating Conceptual Knowledge to Support Simulation-Based Procedural Skills Transfer.

BACKGROUND: Curricular constraints require being selective about the type of content trainees practice in their formal training. Teaching trainees procedural knowledge about "how" to perform steps of a skill along with conceptual knowledge about "why" each step is performed can support skill retention and transfer (i.e., the ability to adapt knowledge to novel problems). However, how best to organize how and why content for procedural skills training is unknown. OBJECTIVES: We examined the impact of different approaches to integrating why and how content on trainees' skill retention and transfer of simulation-based lumbar puncture (LP). DESIGN AND PARTICIPANTS: We randomized medical students (N = 66) to practice LP for 1 h using one of three videos. One video presented only the how content for LP (Procedural Only). Two other videos presented how and why content (e.g., anatomy) in two ways: Integrated in Sequence, with why content followed by how content, or Integrated for Causation, with how and why content integrated throughout. MAIN MEASURES: Pairs of blinded raters scored participants' retention and transfer LP performances on a global rating scale (GRS), and written tests assessed participants' procedural and conceptual knowledge. KEY RESULTS: Simple mediation regression analyses showed that participants receiving an integrated instructional video performed significantly better on transfer through their intervention's positive impact on conceptual knowledge (all p < 0.01). Further, the Integrated for Causation group performed significantly better on transfer than the Integrated in Sequence group (p < 0.01), again mediated by improved conceptual knowledge. We observed no mediation of participants' skill retention (all p > 0.01). CONCLUSIONS: When teaching supports cognitive integration of how and why content, trainees are able to transfer learning to new problems because of their improved conceptual understanding. Instructional designs for procedural skills that integrate how and why content can help educators optimize what trainees learn from each repetition of practice.

'There shouldn't be anything wrong with not knowing': epistemologies in simulation.

CONTEXT: Medical education embraces simulation-based education (SBE). However, key SBE features purported to support learning, such as learner safety and learning through experience and error, may not align with the dominant culture of medicine, in which portraying confidence and certainty about one's knowledge prevails. Misaligned conceptions about knowledge and learning may produce unintended negative effects, including the suboptimal implementation of SBE, which could consequently compromise SBE and its outcomes. METHODS: To uncover the epistemological beliefs of students experiencing SBE, we conducted a theory-informed analysis of interviews with 24 pre-clerkship medical students following their participation in an SBE training study. Our analysis borrowed from coding methods common in constructivist grounded theory and used Hofer and Pintrich's four dimensions of epistemology as sensitising concepts. RESULTS: Participants subscribed to a dominant view of knowledge as consisting of concrete facts, derived from external sources. By contrast, they described but did not prioritise a conception of building their own knowledge through different learning experiences. Participants positioned experts (i.e. teaching faculty members) as the ultimate knowledge validators through their presence and feedback. Participants also noted that faculty staff could counter medicine's pressures to perform with certainty and confidence at all times by instead embodying and modelling an authentic appreciation of learning through experiences, errors and discovery. CONCLUSIONS: Medicine's tendency to idealise the objective pursuit of singular truths may compromise the purported culture of SBE as a space for learning many wide-ranging aspects of medicine, including how and when to innovate and deviate from norms. Explicit attempts to bridge the epistemological beliefs of medicine and SBE may better enable the realisation of safe experiential learning. Faculty members are positioned to play key roles in enabling this bridging.

Supporting self-regulation in simulation-based education: a randomized experiment of practice schedules and goals.

Self-regulated learning is optimized when instructional supports are provided. We evaluated three supports for self-regulated simulation-based training: practice schedules, normative comparisons, and learning goals. Participants practiced 5 endoscopy tasks on a physical simulator, then completed 4 repetitions on a virtual reality simulator. Study A compared two practice schedules: sequential (master each task in assigned order) versus unstructured (trainee-defined). Study B compared normative comparisons framed as success (10% of trainees were successful) versus failure (90% of trainees were unsuccessful). Study C compared a time-only goal (go 1 min faster) versus time + quality goal (go 1 min faster with better visualization and scope manipulation). Participants (18 surgery interns, 17 research fellows, 5 medical/college students) were randomly assigned to groups. In Study A, the sequential group had higher task completion (10/19 vs. 1/21; P < .001), longer persistence attempting an ultimately incomplete task (20.0 vs. 15.9 min; P = .03), and higher efficiency (43% vs. 27%; P = .02), but task time was similar between groups (20.0 vs. 22.6 min; P = .23). In Study B, the success orientation group had higher task completion (10/16 vs. 1/24; P < .001) and longer persistence (21.2 vs. 14.6 min; P = .001), but efficiency was similar (33% vs. 35%; P = .84). In Study C, the time-only group had greater efficiency than time + quality (56% vs. 41%; P = .03), but task time did not differ significantly (172 vs. 208 s; P = .07). In this complex motor task, a sequential (vs. unstructured) schedule, success (vs. failure) orientation, and time-only (vs. time + quality) goal improved some (but not all) performance outcomes.

Assigning Medical Students Learning Goals: Do They Do It, and What Happens When They Don't?

Theory: Medical curricula now include more time for trainees to manage their studying independently, yet evidence suggests that time is not well spent without guidance. Social-cognitivist models of self-regulated learning suggest value when guiding learners to set goals related to their performance processes (actions producing outcomes) versus their performance outcomes (products of performance). Hypotheses: We expected participants oriented to set process goals would demonstrate better suturing skill retention compared with participants oriented to set outcome goals. Method: We randomly assigned 41 medical students to two groups: outcome oriented or process oriented. They self-scored their performance using a visual analog scale on every third trial during 25 training trials, and during 10 retention trials 2 weeks later. Two raters assessed participants' suturing performances (process) and final products (outcome). After finding weak support for our hypothesis, we calculated a "self-monitoring calibration coefficient" as the Pearson's correlation between the raters' average score and each participant's self-scores. We used a mixed-effects analysis of variance to compare participants' performance scores as well as t tests and an analysis of variance to compare their self-monitoring calibration coefficients. Results: Analysis of skill retention data revealed a significant Group × Trial interaction, suggesting a benefit for the process group only for the 10th retention trial (p = .03). During training, the process group had significantly better (p = .02) self-monitoring calibration (r = .71 ± .29) than the outcome group (r = .38 ± .55). In retention, participants in both groups were significantly better calibrated (p = .04) with rater's scores of performance processes (r = .39 ± .60) versus performance outcomes (r = .11 ± .63). Conclusions: Our findings provide limited evidence for our original hypothesis. Perhaps more important, however, our self-monitoring calibration data highlighted inconsistencies between our interventions and our participants' apparent preferences. Not all participants adopted their assigned goal setting orientation, showing that researchers and educators must consider the extent to which trainees adopt imposed instructions in any educational intervention.