The figured world of medical education senior leaders: Making meaning and enacting agency.

INTRODUCTION: The field of medical education is relatively new, and its boundaries are not firmly established. If we had a better understanding of the intricacies of the domain, we might be better equipped to navigate the ever-changing demands we must address. To that end, we explore medical education as a world wherein leaders harness agency, improvisation, discourse, positionality and power to act. METHODS: Using the constructivist theory of figured worlds (FW), we conducted a narrative analysis of the stories medical education senior leaders tell about their roles and experiences in the world of medical education (n = 9). RESULTS: We identified four foundational premises about the world of medical education: (i) medical education stands at the intersection of three interrelated worlds of clinical medicine, hospital administration and university administration; (ii) medical education is shaped by and shapes the clinical learning environment at the local level; (iii) medical education experiences ubiquitous change which is a source of power; and (iv) medical education is energised by relationships between individuals. DISCUSSION: Focusing on the FW theory's notions of agency, improvisation, discourse, positionality and power enabled us to describe the world of medical education as a complex domain existing in a space of conflicting power hierarchies, identities and discourses. Using FW allowed us to see the powerful affordances offered to medical education due to its position between worlds amid unceasing change.

Pushing, standing and bringing to light: How medical trainees conceptualise professional resistance.

BACKGROUND: Much of the literature on harm and injustice in medical education focuses on the impact of oppression rather than trainees' efforts to create change. To acknowledge and make visible these efforts, medical education professionals must grasp how trainees perceive resistance and their role in effecting change. Employing functional linguistic and 'everyday' resistance theories, this critical qualitative study aims to understand trainees' conceptions of resistance practices and their representational choices in moments when they talked about and conceptualised resistance. METHODS: Gathering participants through professional networks and snowball sampling, this study employed in-depth interviews to explore the conceptualisations of resistance among North American medical trainees (9 medical students, 9 residents and fellows). With the use of an applied functional linguistic analysis framework, we analysed the representational metafunction in trainees' conceptualisation of their resistance efforts against social injustice. We began with open coding for 'everyday' acts of resistance and then shifted to focused coding on verbal process types in participants' language to characterise their conceptualisations of resistance. FINDINGS: Participants conceptualised their resistance practices in three distinct ways: first, an almost physical pushing back, drawing largely on material process types (doing); second, an embodied standing up and being present, based predominantly on material and relational process types (being); and third, an epistemic bringing to light, grounded mostly in mental and verbal process types (thinking). These processes of resistance reflect participants' conceptualisations of their efforts to challenge the status quo around inequity, harm and injustice in medical education. CONCLUSION: This study builds on resistance literature, offering a potential typology of resistance practices as pushing back, being and bringing to light. Because these are 'everyday' acts of resistance, these are tactics available to everyone, including faculty; we all have the power to resist, whether it is in teaching and learning or interacting with larger structures in medicine.

Occupying liminal spaces: The figured worlds of student affairs senior leaders in the United States.

INTRODUCTION: Student Affairs Senior Leaders (SASLs) in the United States lead offices responsible for academic advising, administrative documentation, scheduling, student health, financial aid, and transition to residency, yet they infrequently draw attention in the field's literature. We explore the role of SASLs and how they describe the social space of medical education. METHODS: Using a constructivist approach informed by Figured Worlds theory, we conducted a sequential narrative and thematic analysis of the stories SASLs tell about their roles and experiences in the world of medical education. RESULTS: SASLs inhabit complex roles centred on advocating for medical students' academic, personal and social well-being. Their unique position within the medical school allows them to see the harm to vulnerable students made possible by misalignments inherent within medical education. Yet even with the challenges inherent in the environment, SASLs find reasons for hope. CONCLUSION: SASLs' identities are full of potential contradictions, but they have a unique view into the often-chaotic world of medical education.

Essential concepts for effective mixed methods research in the health professions: AMEE Guide No. 173.

Mixed-methods research involves combining quantitative and qualitative approaches and mixing and integrating at multiple stages. It is gaining more attention and interest in health professions education research and evaluation. However, many undertake mixed-methods research for the first time without a rich understanding of the differences in practice associated with mixed-methods research. This often leads to research efforts that do not result in more complex, nuanced understandings of the phenomena being studied. Mixed-methods research requires researchers to thoughtfully and often creatively weave together their projects' various qualitative and quantitative strands. This effort ideally starts at the design stage and continues through the remainder of the research effort. We have aggregated resources and organized this guide to introduce researchers to what we see as some essential concepts, practices, and scholarship in mixed methods which will be useful to those just starting on their mixed-methods journey and those already engaging in mixed-methods research. This guide begins by discussing three vital characteristics of mixed-methods research that set it apart from mono-method research: its purposes, alternative philosophical stances, and integration, long viewed as a defining characteristic. We then discuss further important considerations, such as conducting mixed-methods literature reviews, timing and priority of qualitative and quantitative strands, and research design typologies. To complement these discussions, we have provided illustrative examples of high-quality peer-reviewed mixed-methods research from health professions education and other closely associated areas (e.g. health and clinical research). This guide also includes several activities and recommended resources, such as journals, textbooks, and professional societies, that researchers can use to deepen their practice and understanding and mixed-methods research. We hope the content, resources, article examples, and activities will be the prologue to fruitful explorations of mixed-methods research, helping researchers make informed, intentional choices about future mixed-methods efforts.

In Their Own Voices: A Critical Narrative Review of Black Women Faculty Members' First-Person Accounts of Racial Trauma Across Higher Education.

Phenomenon: Black women often face more challenges in academic medicine than others and are leaving the profession due to unsupportive work environments, systematic neglect, and experiences of invisibility. Research offers insight into Black women faculty experiences, but studies have largely been conducted on their experiences rather than written by them. We analyzed first-person narratives exploring Black women faculty members' experiences with racial trauma across the academy considering the intersectionality of racism and sexism to lay the foundation for understanding Black women physicians' faculty experiences in similar spaces. Approach: We gathered first-person narratives of Black women faculty members in the U.S. from ERIC, Web of Science, and Ovid Medline. We used a variety of terms to draw out potential experiences with trauma (e.g., microaggressions, stigma, prejudice). Articles were screened by two researchers, with a third resolving conflicts. Drawing on constructs from Black feminist theory, two researchers extracted from each article authors' claims about: (a) their institutions, (b) their experiences in those spaces, and (c) suggestions for change. We then analyzed these data through the lens of racial trauma while also noting the effects of gendered racism. Findings: We identified four key themes from the 46 first-person accounts of racial trauma of Black faculty members in higher education: pressures arising from being "the only" or "one of few"; elimination of value through the "cloak of invisibility" and "unconscious assumptions"; the psychological burden of "walking a tightrope"; and communal responsibility, asking "if not us, then who?" Insights: Black women's narratives are necessary to unearth their specific truths as individuals who experience intersectional oppression because of their marginalized racial and gender identities. This may also assist with better understanding opportunities to dismantle the oppressive structures and practices hindering more diverse, equitable, and inclusive institutional environments where their representation, voice, and experience gives space for them to thrive and not simply survive within the academy, including and not limited to medicine.

Towards precision well-being in medical education.

Medical trainee well-being is often met with generalized solutions that overlook substantial individual variations in mental health predisposition and stress reactivity. Precision medicine leverages individual environmental, genetic, and lifestyle factors to tailor preventive and therapeutic interventions. In addition, an exclusive focus on clinical mental illness tends to disregard the importance of supporting the positive aspects of medical trainee well-being. We introduce a novel precision well-being framework for medical education that is built on a comprehensive and individualized view of mental health, combining measures from mental health and positive psychology in a unified, data-driven framework. Unsupervised machine learning techniques commonly used in precision medicine were applied to uncover patterns within multidimensional mental health data of medical students. Using data from 3,632 US medical students, clusters were formulated based on recognized metrics for depression, anxiety, and flourishing. The analysis identified three distinct clusters. Membership in the 'Healthy Flourishers' well-being phenotype was associated with no signs of anxiety or depression while simultaneously reporting high levels of flourishing. Students in the 'Getting By' cluster reported mild anxiety and depression and diminished flourishing. Membership in the 'At-Risk' cluster was associated with high anxiety and depression, languishing, and increased suicidality. Nearly half (49%) of the medical students surveyed were classified as 'Healthy Flourishers', whereas 36% were grouped into the 'Getting-By' cluster and 15% were identified as 'At-Risk'. Findings show that a substantial portion of medical students report diminished well-being during their studies, with a significant number struggling with mental health challenges. This novel precision well-being framework represents an integrated empirical model that classifies individual medical students into distinct and meaningful well-being phenotypes based on their holistic mental health. This approach has direct applicability to student support and can be used to evaluate the effectiveness of personalized intervention strategies stratified by cluster membership.

Are Pre-clerkship Remediation, Grading, and Reporting Practices Equitable in the U.S.? A National Survey.

Phenomenon: With the proliferation of pass/fail grading practices in the pre-clerkship phase of undergraduate medical education, questions arise about the transparency and variability of grading and grade reporting practices, raising issues of equity in assessment, particularly regarding residency matching. The purpose of this survey was to determine the remediation and academic performance reporting practices of United States (U.S.) allopathic medical schools in the pre-clerkship phase of their curricula. Approach: After an extensive literature search and feedback from curriculum deans and learning experts, we developed a survey that we sent in the Spring of 2022 to pre-clerkship curriculum officials at all 154 accredited U.S. allopathic medical schools. It addressed curriculum content and structure; pre-clerkship remediation (e.g., course retakes) and reporting (e.g., permanency of transcript notation) practices; documentation and reporting of nonacademic competencies; and participant opinions and recommendations regarding reporting, transparency, and equity. We generated descriptive statistics and did manifest coding of open-ended responses. Findings: We had a response rate of 40% (62/155), with over 71% indicating mainly organ systems-based curricula. Depending on the situation, there were a wide range of remediation approaches for single- and multiple-course failures, including tutoring or learning support, re-exams, and referrals to a promotion board. Professionalism concerns were a top priority to report to residency directors, with significant variability in respondent opinions and practices in reporting remedial activities. Respondents were concerned about equity, both in terms of flexible grading practices and transparency of reporting practices. Insights: The variability in reporting practices across schools, while allowing holistic and individualized approaches to academic support, also creates potential inequities. More work is needed to understand how different reporting practices across institutions may disadvantage marginalized and minoritized student groups at different points in their preparation.

Past resources, future envisioning, and present positioning: how women who are medical students at one institution draw upon temporal agency for resistance.

While women entering medical school are faced with a patriarchal system, they also enter into a community with other women and the potential for resistance. The purpose of this study is to use the theory of temporal agency to explore how first-year medical students who identify as women draw upon past, future, and present agency to resist the patriarchal system of medicine.The data for this study were drawn from the first year (October 2020-April 2021) of a longitudinal project using narrative inquiry to understand the socialization of women students in undergraduate medical education. Fifteen participants performed two interviews and a series of written reflection prompts about their childhood and medical school experiences, each lasting approximately 45 min.Participants' resistance drew on past resources, recognizing themselves as Other, which contributed to categorically locating themselves as part of a broader resisting community, even outside their institution. They also hypothesized future possibilities as part of resistance, either an ideal future where they would exercise power, or an unchanged one and the hypothetical resolutions they would use to manage it. Finally, they contextualized past and future in the present, identifying problems to make strategic decisions and execute actions.Our creative interweaving of the constructs of temporal agency, communal agency, and resistance allows us to paint a nuanced picture of how these women conceive of themselves as part of a larger group of women amidst the hierarchical, patriarchal structures of medical school while, at times, internalizing these hierarchies.

Putting on Academic Armor: How Black Physicians and Trainees Take Stances to Make Racism Visible Amid Publishing Constraints.

Starting with reflexivity: As a Black woman medical student at a predominately white institution, a white woman full professor and deputy editor-in-chief of a journal, and a white woman associate professor with a deep interest in language, we understand that medicine and medical education interpellate each of us as a particular kind of subject. As such, we begin with a narrative grounding in our personal stances. Phenomenon: While there are a growing number of empirical studies of Black physicians' and trainees' experiences of racism, there are still few accounts from a first-person perspective. Black authors of these personal commentaries or editorials, who already experience microaggressions and racial trauma in their work spaces, must put on their academic armor to further experience them in publishing spaces. This study seeks to understand the stances Black physicians and trainees take as they share their personal experiences of racism. Approach: We searched four databases, identifying 29 articles authored by Black physicians and trainees describing their experiences. During initial analysis, we identified and coded for three sets of discursive strategies: identification, intertextuality, and space-time. Throughout the study, we reflected on our own stances in relation to the experience of conducting the study and its findings. Findings: Authors engaged in stance-taking, which aligned with the concept of donning academic armor, by evaluating and positioning themselves with respect to racism and the norms of academic discourse in response to ongoing conversations both within medicine and in the broader U.S. culture. They did this by (a) positioning themselves as being Black and, therefore, qualified to notice and name personal racist experiences while also aligning themselves with the reader through shared professional experiences and goals; (b) intertextual connections to other related events, people, and institutions that they-and their readers-value; and (c) aligning themselves with a hoped-for future rather than a racist present. Personal insights: Because the discourses of medicine and medical publishing interpellate Black authors as Others they must carefully consider the stances they take, particularly when naming racism. The academic armor they put on must be able to not only defend them from attack but also help them slip unseen through institutional bodies replete with mechanisms to eject them. In addition to analyzing our own personal stance, we leave readers with thought-provoking questions regarding this armor as we return to narrative grounding.

Do All Roads Lead to Full Participation? Examining Trajectories of Clinical Educators in Graduate Medical Education through Situated Learning Theory.

Phenomenon: As new faculty members begin their careers in Graduate Medical Education, each begins a journey of Professional Identity Formation from the periphery of their educational communities. The trajectories traveled vary widely, and full participation in a given educational community is not assured. While some medical school and post-graduate training programs may nurture Professional Identity Formation, there is scant support for faculty. To date, the trajectories that Graduate Medical Education faculty travel, what may derail inbound trajectories, and what tools Graduate Medical Education faculty use to navigate these trajectories have not been explicitly described. We explore these three questions here. Approach: Communities of Practice, a component of Situated Learning Theory, serves as a helpful framework to explore trajectories of educator identity development among Graduate Medical Educators. We used a inductive and deductive approach to Thematic Analysis, with Situated Learning Theory as our interpretive frame. Semi-structured interviews of faculty members of GME programs matriculating into a Health Professions Education Program were conducted, focusing on participants' lived experiences in medical education and how these experiences shaped their Professional Identity Formation. Findings: Participants noted peripheral, inbound, boundary, and outbound trajectories, but not an insider trajectory. Trajectory derailment was attributed to competing demands, imposter syndrome and gendered marginality. Modes of belonging were critical tools participants used to shape PIF, not only engagement with educator roles but disengagement with other roles; imagination of future roles with the support of mentors; and fluid alignment with multiple mutually reinforcing identities. Participants identified boundary objects like resumes and formal roles that helped them negotiate across Community of Practice boundaries. Insights: Despite a desire for full participation, some clinical educators remain marginal, struggling along a peripheral trajectory. Further research exploring this struggle and potential interventions to strengthen modes of belonging and boundary objects is critical to create equitable access to the inbound trajectory for all of our colleagues, leaving the choice of trajectories up to them.

Teaching at the Convergence of Pandemics and Historically Excluded Patient Populations: The Challenges, and Importance, of Culturally Responsive Communication.

Issue: Historically excluded patient populations-particularly racial, ethnic, and sexually and gender minoritized people-experience gross inequities in health, worsened by the HIV and COVID-19 pandemics. Culturally responsive communication (CRC) is a vital tool health professionals can use to address these inequities. Yet, CRC can be challenging to teach, particularly during pandemics. The authors argue that pandemics magnify the powerful intersecting oppressions of heterosexism, racism, transphobia, nationalism, and sexism, essentially targeting Othered bodies for dying, a phenomenon known as necropolitics. Evidence: Five aspects of pandemics make teaching CRC more difficult and, because of the magnification of necropolitics, more critical. First, pandemics heighten teachers' and learners' personal frailties, engendering worries about their own and their families' health and increasing cognitive load. This can make it difficult for them to embrace the discomfort required of CRC, particularly when an increased patient load is squeezing instructional time. Second, guidelines for HIV and COVID-19 testing, prevention, and treatment are ever-changing, often faster than the pace of curriculum development and instructor professional development. Third, for instructors who may already be stretched thin, it is challenging to prepare learners for the variability in how their future practice contexts may address HIV and COVID-19 and, further, how to take a social justice approach to assess and resist the distinct equity issues of each of these contexts. Fourth, pandemics cause uncertain access to patient information about testing, disease status, and vaccination or pre-exposure prophylaxis. This worsens already disparate outcomes for minoritized patients and adds to the complexity of CRC curricula. Finally, virtual care is more prevalent in pandemics and teaching CRC in online contexts can be difficult. Implications: To address these challenges, we adopt the Dimensionality and R4P Health Equity Framework as a tool for evaluating academic programs for CRC so that it remains robust amidst pandemics. This tool addresses the varied social positions and identities (i.e., "dimensions") that present different opportunities for health. We offer specific evaluation questions programs can ask and approaches they can take to (a) redress past harms through removing existing racist, heteronormative and transphobic structures and repairing the damage they have done; (b) plan for a more equitable future by restructuring via policy and organizational change and providing programs that address intersectional disadvantage; and (c) critically evaluate the present by remediating current damage immediately until restructuring efforts are fully functional. As Martin Luther King, Jr. stated, "Of all the forms of inequality, injustice in healthcare is the most shocking and inhuman because it often results in physical death." It is our imperative to teach CRC with intentionality; otherwise we will support necropolitics as we continue to condone disproportionate morbidity and mortality for racialized and queer bodies.

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.

The potential of narrative analysis for HPE research: Highlighting five analytic lenses.

CONTEXT: Health professions education (HPE) has increasingly turned to qualitative methodology to address a number of the field's difficult research problems. While several different methodologies have been widely accepted and used in HPE research (e.g., Grounded Theory), others remain largely unknown. In this methodology paper, we discuss the value of narrative analysis (NA) as a set of analytic approaches that offer several lenses that can support HPE scholars' research. METHODS: After briefly discussing the 'narrative turn' in research, we highlight five NA lenses: holistic, situated, linguistic, agentive and sequential. We explore what each lens can offer HPE scholars-highlighting certain aspects of the data-and how each lens is limited-obscuring other aspects. To support these observations, we offer an example of each lens from contemporary HPE scholarship. The manuscript also describes methods that can be employed in NA research and offers two different typologies of NA methods that can be used to access these lenses. CONCLUSIONS: We conclude with a discussion of how different analytic methods can be used to harness each of the lenses. We urge the deliberate selection and use of NA methods and point to the inherent partiality of any NA approach. Reflecting on our position as narrative scholars, we acknowledge how our own lenses illuminate some areas and conceal others as we tell the story of NA. In conclusion, we invite other researchers to benefit from the potential NA promises.

Why health professions education needs functional linguistics: the power of 'stealth words'.

CONTEXT: Language is one of the primary modalities for teaching and learning in the health professions in contexts ranging from the more formal teaching relationships of medical school to the guided practice of trainees through continuing education and the deliberate practice of lifelong learning. Yet linguistic analysis, with the possible exception of discourse analysis, has not become a core methodological tool in the field of health professions education (HPE). The purpose of this paper is to argue for the more widespread adoption of one particular approach to linguistics, one that examines less of what learners and instructors say and looks more at how they say it: functional linguistics. FUNCTIONAL LINGUISTICS: THE POWER OF 'STEALTH WORDS': This approach theorises and structures the functions of language, regularly focusing attention on 'stealth words' such as I, but and was. Drawing on a rich body of literature in linguistics, psychology, the learning sciences and some early work in HPE, we demonstrate how functional linguistic tools can be applied to better understand learners' and instructors' beliefs, reasoning processes, values and emotions. FUNCTIONAL LINGUISTICS AND REFLECTION: AN APPLICATION OF STEALTH WORDS: A brief qualitative analysis of one tool - analysis of the generic use of 'you' to mean 'one' or 'anyone' - demonstrates how functional linguistics can offer insight into physicians' bids for credibility and alignment as they think aloud about their clinical reasoning. FUNCTIONAL LINGUISTICS AND HPE: FUTURE DIRECTIONS: Finally, we offer suggestions for how functional linguistic tools might address questions and gaps in four active research areas in HPE: reflection; emotion and reasoning; learning in simulated contexts, and self-regulated learning. CONCLUSIONS: We argue that the words used by learners, instructors and practitioners in the health professions as they move through undergraduate and graduate training into practice can offer clues that will help researchers, instructors and colleagues to better support them.

First-year medical students' calibration bias and accuracy across clinical reasoning activities.

To be safe and effective practitioners and learners, medical professionals must be able to accurately assess their own performance to know when they need additional help. This study explored the metacognitive judgments of 157 first-year medical students; in particular, the study examined students' self-assessments or calibration as they engaged in a virtual-patient simulation targeting clinical reasoning practices. Examining two key subtasks of a patient encounter, history (Hx) and physical exam (PE), the authors assessed the level of variation in students' behavioral performance (i.e., effectiveness and efficiency) and judgments of performance (i.e., calibration bias and accuracy) across the two subtasks. Paired t tests revealed that the Hx subtask was deemed to be more challenging than the PE subtask when viewed in terms of both actual and perceived performance. In addition to students performing worse on the Hx subtask than PE, they also perceived that they performed less well for Hx. Interestingly, across both subtasks, the majority of participants overestimated their performance (98% of participants for Hx and 95% for PE). Correlation analyses revealed that the participants' overall level of accuracy in metacognitive judgments was moderately stable across the Hx and PE subtasks. Taken together, findings underscore the importance of assessing medical students' metacognitive judgments at different points during a clinical encounter.

How Theory Can Inform Practice: A Case of Easing Transition Into Residency.

Health professions educators aim to optimally prepare trainees for future practice; educational theory can help reach this goal. Below we present an authentic case, I Just Need to Speak With My Eyes, that displays the significant struggles of transitioning into residency training. Using this case, we show how the application of 4 learning mechanisms described in Lave and Wenger's 1,2 theories of situated learning and communities of practice can help ease the transition into residency by addressing issues like self-questioning and emotional turmoil (see the colored boxes below). Situated learning refers to learning in everyday practice and highlights its fundamentally social nature as well as the progressive participation of the learner. 1 Communities of practice builds on the notion of people learning from each other, viewing learning as a shared enterprise among a group of people with a common purpose. 2.

Conceptualizing National Advisory Boards in primary care research: application to the Two in One HIV and COVID screening and testing model.

The authors report on their development of a National Advisory Board (NAB) to guide a funded project: Two in One: HIV + COVID-19 Screening and Testing Model. This project aimed to improve primary care practitioners' capacity to routinize HIV, PrEP/PEP, and COVID-19 vaccine screenings for all their patients while relying on culturally responsive communication with their minoritized patients. To approach their monumental research and education tasks, they created a NAB, drawing from the literature on advisory boards to (a) promote board member engagement and (b) progress successfully through the six stages suggested for successful advisory boards. A midpoint survey and final focus groups with NAB members indicated mixed levels of engagement, a sense of time and work being valued, and pride in the media and academic reach of the project. The authors offer considerations for others considering forming a NAB to guide primary care research and interventions.

How Advanced Practice Clinicians Support Education for and Contribute to Education of Graduate Medical Education Trainees: A Critical Literature Review.

PURPOSE: With the introduction of physician assistants and nurse practitioners (i.e., advanced practice clinicians [APCs]), the landscape of graduate medical education (GME) has fundamentally changed. Whereas APCs' role in GME settings has been mainly described as substitutes for postgraduate medical trainees, APCs are increasingly considered integrated and collaborative team members. However, APCs' contributions to trainees' education and learning remain underexplored. This critical review synthesized the literature available on how APCs contribute to trainees' workplace learning and how these contributions are enabled. METHOD: The authors searched PubMed, Embase, Web of Science, CINAHL, and PsycINFO for articles published from database inception dates through April 2023 for articles reporting on educational or guiding behaviors of APCs in GME contexts, resulting in 1,830 articles for possible inclusion. Using a critical review approach, the analysis was informed by a previously published framework describing workplace guidance behaviors and the authors' clinical and research expertise. RESULTS: A total of 58 articles were included in the study. Advanced practice clinicians contribute to trainees' workplace learning through a variety of guidance behaviors, including learning from patient care, demonstrating, support, socialization, feedback, involvement in evaluations, and other unspecified contributions. Thematic analysis indicated that APCs' contributions were enabled by their close working relationships with trainees, their unique perspective within the workplace, and the extent to which they were formally incorporated within workplace learning. CONCLUSIONS: This critical review offers a concrete description of ways APCs are contributing to trainees' learning and education in the GME workplace across the literature. These results suggest that APCs could be a potentially untapped source for further optimizing workplace learning. However, unlocking this potential will require a shift in the conceptualization of APCs' role in the workplace. Opportunities for APC professional development and formalization of APCs' educational role should be considered.