Programmatic Assessment of Clinical Reasoning: New Opportunities to Meet an Ongoing Challenge.

Issue: Clinical reasoning is essential to physicians' competence, yet assessment of clinical reasoning remains a significant challenge. Clinical reasoning is a complex, evolving, non-linear, context-driven, and content-specific construct which arguably cannot be assessed at one point in time or with a single method. This has posed challenges for educators for many decades, despite significant development of individual assessment methods. Evidence: Programmatic assessment is a systematic assessment approach that is gaining momentum across health professions education. Programmatic assessment, and in particular assessment for learning, is well-suited to address the challenges with clinical reasoning assessment. Several key principles of programmatic assessment are particularly well-aligned with developing a system to assess clinical reasoning: longitudinality, triangulation, use of a mix of assessment methods, proportionality, implementation of intermediate evaluations/reviews with faculty coaches, use of assessment for feedback, and increase in learners' agency. Repeated exposure and measurement are critical to develop a clinical reasoning assessment narrative, thus the assessment approach should optimally be longitudinal, providing multiple opportunities for growth and development. Triangulation provides a lens to assess the multidimensionality and contextuality of clinical reasoning and that of its different, yet related components, using a mix of different assessment methods. Proportionality ensures the richness of information on which to draw conclusions is commensurate with the stakes of the decision. Coaching facilitates the development of a feedback culture and allows to assess growth over time, while enhancing learners' agency. Implications: A programmatic assessment model of clinical reasoning that is developmentally oriented, optimizes learning though feedback and coaching, uses multiple assessment methods, and provides opportunity for meaningful triangulation of data can help address some of the challenges of clinical reasoning assessment.

Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research.

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

'You don't see what I see': Co-designing simulation to uncover and address cognitive bias in healthcare.

EDUCATIONAL CHALLENGE: Each year, adverse events are reported in healthcare, of which many relate to healthcare workforce cognitive bias. The active involvement of workforce and consumers in the review and co-design of effective training for the healthcare workforce to recognise, monitor, and manage unconscious bias is required. PROPOSED SOLUTION: We used participatory action research to co-design an innovative, interprofessional simulation based on 'real world' clinical incidents and lived experiences to improve the delivery of safe, high quality, consumer-focused healthcare. Following ethics approval, content analysis of serious adverse patient safety events involving cognitive bias was conducted. These data informed audio-recorded interviews with the healthcare workforce and consumers to explore their experiences of cognitive bias. Following thematic analysis, key themes of communication, stigma, diagnostic overshadowing, and fragmented systems were uncovered. Guided by consumers, these themes were interwoven into a simulation scenario that included real places, stories, and verbatim quotes delivered through mixed media artefacts. This heightened the immersive and experiential learning that aimed to uncover unconscious bias and help learners recognise its impact on clinical decisions and practice. POTENTIAL BENEFITS AND NEXT STEPS: To our knowledge, this is the first interprofessional, co-designed simulation to specifically address cognitive bias in current and future healthcare workforce. Plans to translate this research into a practical framework on how to work with key stakeholders (including consumers) to identify 'real-world' health service risks and co-design targeted simulations to address these gaps are described, including lessons learned.

A scoping review of artificial intelligence in medical education: BEME Guide No. 84.

BACKGROUND: Artificial Intelligence (AI) is rapidly transforming healthcare, and there is a critical need for a nuanced understanding of how AI is reshaping teaching, learning, and educational practice in medical education. This review aimed to map the literature regarding AI applications in medical education, core areas of findings, potential candidates for formal systematic review and gaps for future research. METHODS: This rapid scoping review, conducted over 16 weeks, employed Arksey and O'Malley's framework and adhered to STORIES and BEME guidelines. A systematic and comprehensive search across PubMed/MEDLINE, EMBASE, and MedEdPublish was conducted without date or language restrictions. Publications included in the review spanned undergraduate, graduate, and continuing medical education, encompassing both original studies and perspective pieces. Data were charted by multiple author pairs and synthesized into various thematic maps and charts, ensuring a broad and detailed representation of the current landscape. RESULTS: The review synthesized 278 publications, with a majority (68%) from North American and European regions. The studies covered diverse AI applications in medical education, such as AI for admissions, teaching, assessment, and clinical reasoning. The review highlighted AI's varied roles, from augmenting traditional educational methods to introducing innovative practices, and underscores the urgent need for ethical guidelines in AI's application in medical education. CONCLUSION: The current literature has been charted. The findings underscore the need for ongoing research to explore uncharted areas and address potential risks associated with AI use in medical education. This work serves as a foundational resource for educators, policymakers, and researchers in navigating AI's evolving role in medical education. A framework to support future high utility reporting is proposed, the FACETS framework.

Evaluation of bias and gender/racial concordance based on sentiment analysis of narrative evaluations of clinical clerkships using natural language processing.

There is increasing interest in understanding potential bias in medical education. We used natural language processing (NLP) to evaluate potential bias in clinical clerkship evaluations. Data from medical evaluations and administrative databases for medical students enrolled in third-year clinical clerkship rotations across two academic years. We collected demographic information of students and faculty evaluators to determine gender/racial concordance (i.e., whether the student and faculty identified with the same demographic). We used a multinomial log-linear model for final clerkship grades, using predictors such as numerical evaluation scores, gender/racial concordance, and sentiment scores of narrative evaluations using the SentimentIntensityAnalyzer tool in Python. 2037 evaluations from 198 students were analyzed. Statistical significance was defined as P < 0.05. Sentiment scores for evaluations did not vary significantly by student gender, race, or ethnicity (P = 0.88, 0.64, and 0.06, respectively). Word choices were similar across faculty and student demographic groups. Modeling showed narrative evaluation sentiment scores were not predictive of an honors grade (odds ratio [OR] 1.23, P = 0.58). Numerical evaluation average (OR 1.45, P < 0.001) and gender concordance between faculty and student (OR 1.32, P = 0.049) were significant predictors of receiving honors. The lack of disparities in narrative text in our study contrasts with prior findings from other institutions. Ongoing efforts include comparative analyses with other institutions to understand what institutional factors may contribute to bias. NLP enables a systematic approach for investigating bias. The insights gained from the lack of association between word choices, sentiment scores, and final grades show potential opportunities to improve feedback processes for students.

Students' Perspectives on Basic and Clinical Science Integration When Step 1 is Administered After the Core Clerkships.

Phenomenon: According to adult learning theories, effective cognitive integration of basic and clinical science may promote the transfer of knowledge to patient care. The placement of the U.S. Medical Licensing Examination (USMLE) Step 1 after the core clerkships is one strategy intended to facilitate cognitive integration, though learner experiences with this model are unexplored. The purpose of this study is to understand students' perspectives on basic and clinical science integration in a post-clerkship Step 1 curriculum. Approach: Focus groups were conducted between August and September 2020 with senior medical students from the University of California, San Francisco School of Medicine and University of Michigan Medical School. Data were analyzed using a constructivist approach to thematic analysis. Findings: Thirty-three students participated in six focus groups. Participants described multiple barriers to cognitive integration in the clerkship learning environment, though they also identified examples of teaching and learning that facilitated integration. Early in their clerkships, students struggled to integrate because of their tenuous basic science foundation, cognitive overload, and difficulty perceiving the relevance of basic science to patient care. They felt that educators primarily focused on clinical science, and many basic science teaching sessions during clerkships felt irrelevant to patient care. However, students also described experiences that made the connection between basic and clinical science more explicit, including modeling by educators and clerkship learning activities that more overtly encouraged the application of basic science to clinical care. In addition, the return to basic science studying during the post-clerkship dedicated Step 1 study period offered powerful integration opportunities. These facilitators of cognitive integration helped students recognize the value of integration for enduring learning. Insights: There are myriad barriers to cognitive integration of basic and clinical science during clerkships in a post-clerkship Step 1 curriculum. The relevance of basic science to patient care needs to be made more explicit to students through modeling by clinician educators to augment the potential benefits of curricular change. The post-clerkship Step 1 study period appears to offer a unique opportunity for cognitive integration later in a learner's trajectory that may be related to curricular design. When learners recognize the applicability of basic science to patient care, they may more intentionally transfer basic science knowledge to clinical practice.

Dealing with uncertainty in clinical reasoning: A threshold model and the roles of experience and task framing.

INTRODUCTION: Uncertainty is integral to clinical practice and clinical reasoning but has proven difficult to study and model. Little is known about how clinicians manage uncertainty. According to evidence-based medicine theory, clinicians should utilise new information to reduce uncertainty until reaching action thresholds for further information gathering or treatment. We examined the impact of experience and task framing on uncertainty thresholds and the extent to which these thresholds guided clinical decisions. Finally, we sought to determine the impact of framing by having participants provide threshold responses as a range or as specific numbers. METHODS: One hundred sixty-eight fourth-year medical students, 93 residents and 72 faculty were presented a case of viral pneumonia with a suspected superimposed bacterial infection. Participants identified their testing and treatment thresholds with either a specific number or an inter-threshold range of probabilities that would compel them to test further. Afterwards, they were told the patient had a 20% pre-test probability of a superimposed infection and asked whether they would treat the patient with antibiotics, order additional testing or neither. Responses were compared with their previously stated threshold values to assess decision-making consistency. RESULTS: Testing thresholds were 15.8%, 20.6% and 25.8%, treatment thresholds were 78.5%, 71.6% and 73.4% and threshold spans (difference between testing and treatment thresholds) were 62.7, 51 and 47.6 for students, residents and faculty, respectively. Sixty-four percent of respondents made judgements consistent with their thresholds, 28% escalated their decision (doing more than their thresholds predicted) and 7.6% de-escalated their decision (doing less than their thresholds predicted). Framing had an impact on both faculty and resident decisions and a larger impact on students. DISCUSSION: These findings help us understand how clinical reasoning and threshold determinations vary with clinical experience. As uncertainty can lead to unnecessary testing and cognitive discomfort, examining decision thresholds helps us ascertain how diagnostic and treatment decisions are made.

Pivot to online learning for adapting or continuing workplace-based clinical learning in medical education following the COVID-19 pandemic: A BEME systematic review: BEME Guide No. 70.

BACKGROUND: The novel coronavirus disease was declared a pandemic in March 2020, which necessitated adaptations to medical education. This systematic review synthesises published reports of medical educational developments and innovations that pivot to online learning from workplace-based clinical learning in response to the pandemic. The objectives were to synthesise what adaptations/innovation were implemented (description), their impact (justification), and 'how' and 'why' these were selected (explanation and rationale). METHODS: The authors systematically searched four online databases up to December 21, 2020. Two authors independently screened titles, abstracts and full-texts, performed data extraction, and assessed the risk of bias. Our findings are reported in alignment with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance. RESULTS: Fifty-five articles were included. Most were from North America (n = 40), and nearly 70% focused on undergraduate medical education (UGME). Key developments were rapid shifts from workplace-based learning to virtual spaces, including online electives, telesimulation, telehealth, radiology, and pathology image repositories, live-streaming or pre-recorded videos of surgical procedures, stepping up of medical students to support clinical services, remote adaptations for clinical visits, multidisciplinary team meetings and ward rounds. Challenges included lack of personal interactions, lack of standardised telemedicine curricula and need for faculty time, technical resources, and devices. Assessment of risk of bias revealed poor reporting of underpinning theory, resources, setting, educational methods, and content. CONCLUSIONS: This review highlights the response of medical educators in deploying adaptations and innovations. Whilst few are new, the complexity, concomitant use of multiple methods and the specific pragmatic choices of educators offers useful insight to clinical teachers who wish to deploy such methods within their own practice. Future works that offer more specific details to allow replication and understanding of conceptual underpinnings are likely to justify an update to this review.

Online learning developments in undergraduate medical education in response to the COVID-19 pandemic: A BEME systematic review: BEME Guide No. 69.

BACKGROUND: The COVID-19 pandemic spurred an abrupt transition away from in-person educational activities. This systematic review investigated the pivot to online learning for nonclinical undergraduate medical education (UGME) activities and explored descriptions of educational offerings deployed, their impact, and lessons learned. METHODS: The authors systematically searched four online databases and conducted a manual electronic search of MedEdPublish up to December 21, 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias. A third author resolved discrepancies. Findings were reported in accordance with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance. RESULTS: Fifty-six articles were included. The majority (n = 41) described the rapid transition of existing offerings to online formats, whereas fewer (n = 15) described novel activities. The majority (n = 27) included a combination of synchronous and asynchronous components. Didactics (n = 40) and small groups (n = 26) were the most common instructional methods. Teachers largely integrated technology to replace and amplify rather than transform learning, though learner engagement was often interactive. Thematic analysis revealed unique challenges of online learning, as well as exemplary practices. The quality of study designs and reporting was modest, with underpinning theory at highest risk of bias. Virtually all studies (n = 54) assessed reaction/satisfaction, fewer than half (n = 23) assessed changes in attitudes, knowledge or skills, and none assessed behavioral, organizational or patient outcomes. CONCLUSIONS: UGME educators successfully transitioned face-to-face instructional methods online and implemented novel solutions during the COVID-19 pandemic. Although technology's potential to transform teaching is not yet fully realized, the use of synchronous and asynchronous formats encouraged virtual engagement, while offering flexible, self-directed learning. As we transition from emergency remote learning to a post-pandemic world, educators must underpin new developments with theory, report additional outcomes and provide details that support replication.

Remote learning developments in postgraduate medical education in response to the COVID-19 pandemic - A BEME systematic review: BEME Guide No. 71.

BACKGROUND: Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners. METHODS: Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned. RESULTS: Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities (n Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment. CONCLUSIONS: This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.

Virtual interviewing for graduate medical education recruitment and selection: A BEME systematic review: BEME Guide No. 80.

BACKGROUND: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses. METHODS: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance. RESULTS: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel. CONCLUSIONS: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

Exploring Students' Perspectives on Well-Being and the Change of United States Medical Licensing Examination Step 1 to Pass/Fail.

PHENOMENON: In February 2020, the Federation of State Medical Boards and National Board of Medical Examiners announced that Step 1 of the United States Medical Licensing Examination would transition from a three-digit numerical score to a pass/fail outcome. While several opinion pieces have been authored on the potential implications of this change, no study has formally assessed the student voice. The purpose of this study is to explore medical students' perspectives of a pass/fail Step 1, with an emphasis on how this transition will impact their well-being. Approach: We conducted virtual focus groups from May 2020-June 2020 with first- and second-year medical students from six institutions (n = 30). We analyzed focus group content following the inductive and iterative constructivist approach to produce a thematic analysis. Findings: Participants included females (50%), males (47%), and one non-binary student. The majority were Caucasian (57%), followed by Asian (27%), African American (10%), and Hispanic or Latino/a (7%). Overall, students were confused regarding the decision to transition Step 1 to a pass/fail outcome. They expressed anxiety over the uncertainty of how a pass/fail Step 1 may impact future residency applications and pressure to re-allocate time and resources to other academic pursuits that would make them competitive. Students explicitly stated skepticism or disbelief that a pass/fail Step 1 would improve their well-being. Insights: While the decision to make Step 1 pass/fail was in part intended to decrease stress associated with performance on a single high-stakes exam designed for licensing purposes, it has led to increased worries for students, and secondary, unanticipated consequences remain to be seen. In this new setting, it will be imperative to provide clarity regarding the metrics used to evaluate students and to incorporate their perspectives in future policy changes.

Does Delaying the United States Medical Licensing Examination Step 1 to After Clerkships Affect Student Performance on Clerkship Subject Examinations?

Phenomenon: Schools are considering the optimal timing of Step 1 of the United States Medical Licensing Examination (USMLE). Two primary reasons for moving Step 1 after the core clerkships are to promote deeper, more integrated basic science learning in clinical contexts and to better prepare students for the increasingly clinical focus of Step 1. Positioning Step 1 after the core clerkships leverages a major national assessment to drive learning, encouraging students to deepen their basic science knowledge while in the clinical setting. Previous studies demonstrated small increases in Step 1 scores, reductions in failure rates, and similar Step 2 Clinical Knowledge scores when Step 1 was after the clerkships. Some schools that have moved Step 1 reported declines in clinical subject examination (CSE) performance. This may be due to shortened pre-clerkship curricula, the absence of the Step 1 study period for knowledge consolidation, or exposure to fewer National Board of Medical Examiners type questions prior to taking CSEs. This multi-institutional study aimed to determine whether student performance on CSEs was affected by moving Step 1 after the core clerkships. Approach: CSE scores for students from eight schools that moved Step 1 after core clerkships between 2012 and 2016 were analyzed in a pre-post format. Hierarchical linear modeling was used to quantify the effect of the curriculum on CSE performance. Additional analysis determined if clerkship order impacted clinical subject exam performance and whether the curriculum change resulted in more students scoring in the lowest percentiles (as defined as below the national fifth percentile) before and after the curricular change. Findings: After moving Step 1 to after the clerkships, collectively these eight schools demonstrated statistically significant lower performance on four CSEs (Medicine, Neurology, Pediatrics, and Surgery) but not Obstetrics/Gynecology or Psychiatry. Comparing performance within the three years pre and post Step 1 change, differences across all clerkships ranged from 0.3 to -2.0 points, with an average difference of -1.1. CSE performance in clerkships taken early in the sequence was more affected by the curricular change, and differences gradually disappeared with subsequent examinations. Medicine and Neurology showed the largest average differences between curricular-group when taken early in the clinical year. Finally, there was a slightly higher chance of scoring below the national fifth percentile in four of the clinical subject exams (Medicine, Neurology, Pediatrics, and Psychiatry) for the cohort with Step 1 after the clerkships. Insights: Moving Step 1 after core clerkships had a small impact on CSE scores overall, with decreased scores for exams early in the clerkship sequence and an increased number of students below the fifth percentile. Score differences have minor effects on clerkship grades, but overall the size of the effect is unlikely to be educationally meaningful. Schools can use a variety of mitigation strategies to address CSE performance and Step 1 preparation in the clerkship phase.

Incidence of resident mistreatment in the learning environment across three institutions.

INTRODUCTION: Mistreatment in the learning environment is associated with negative outcomes for trainees. While the Association of American Medical Colleges (AAMC) annual Graduation Questionnaire (GQ) has collected medical student reports of mistreatment for a decade, there is not a similar nationally benchmarked survey for residents. The objective of this study is to explore the prevalence of resident experiences with mistreatment. METHODS: Residents at three academic institutions were surveyed using questions similar to the GQ in 2018. Quantitative data were analyzed based on frequency and Mann-Whitney U tests to detect gender differences. RESULTS: Nine hundred ninety-six of 2682 residents (37.1%) responded to the survey. Thirty-nine percent of residents reported experiencing at least one incident of mistreatment. The highest reported incidents were public humiliation (23.7%) and subject to offensive sexist remarks/comments (16.0%). Female residents indicated experiencing significantly more incidents of public embarrassment, public humiliation, offensive sexist remarks, lower evaluations based on gender, denied opportunities for training or rewards, and unwanted sexual advances. Faculty were the most frequent instigators of mistreatment (66.4%). Of trainees who reported experiencing mistreatment, less than one-quarter reported the behavior. CONCLUSION: Mistreatment in the academic learning environment is a concern in residency programs. There is increased frequency among female residents.

An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64.

BACKGROUND: COVID-19 has fundamentally altered how education is delivered. Gordon et al. previously conducted a review of medical education developments in response to COVID-19; however, the field has rapidly evolved in the ensuing months. This scoping review aims to map the extent, range and nature of subsequent developments, summarizing the expanding evidence base and identifying areas for future research. METHODS: The authors followed the five stages of a scoping review outlined by Arskey and O'Malley. Four online databases and MedEdPublish were searched. Two authors independently screened titles, abstracts and full texts. Included articles described developments in medical education deployed in response to COVID-19 and reported outcomes. Data extraction was completed by two authors and synthesized into a variety of maps and charts. RESULTS: One hundred twenty-seven articles were included: 104 were from North America, Asia and Europe; 51 were undergraduate, 41 graduate, 22 continuing medical education, and 13 mixed; 35 were implemented by universities, 75 by academic hospitals, and 17 by organizations or collaborations. The focus of developments included pivoting to online learning (n = 58), simulation (n = 24), assessment (n = 11), well-being (n = 8), telehealth (n = 5), clinical service reconfigurations (n = 4), interviews (n = 4), service provision (n = 2), faculty development (n = 2) and other (n = 9). The most common Kirkpatrick outcome reported was Level 1, however, a number of studies reported 2a or 2b. A few described Levels 3, 4a, 4b or other outcomes (e.g. quality improvement). CONCLUSIONS: This scoping review mapped the available literature on developments in medical education in response to COVID-19, summarizing developments and outcomes to serve as a guide for future work. The review highlighted areas of relative strength, as well as several gaps. Numerous articles have been written about remote learning and simulation and these areas are ripe for full systematic reviews. Telehealth, interviews and faculty development were lacking and need urgent attention.

The educators' experience: Learning environments that support the master adaptive learner.

BACKGROUND: The Master Adaptive Learner (MAL) theoretical framework describes an integrated approach to learning that combines features of educational theory on self-regulated learning and aspects of quality improvement. In order to develop MAL students, it is important to pay attention to the learning environment. PURPOSE: To describe educators' perspectives about the learning environment needed to promote the development of master adaptive learners. METHODS: Thematic analysis of reports by medical educators who were workshop participants at a national presentation on creating effective learning environment to develop MAL in undergraduate medical education. RESULTS: Three themes educators considered important in the development of the Master Adaptive Learner were Adaptive Educator, Support for Learning, and Institutional Commitment. These findings suggest that in order to support the MAL, an educational setting should provide faculty who can be flexible and adapt to the developing MAL, learning experiences that support active learning, focused on groups as well as developing individual learners. Leaders in the educational setting should demonstrate a commitment to creating a culture to support learning and provide appropriate resources to that end. CONCLUSION: Learning environments to develop master adaptive learners need to have adaptive educators, teaching, learning, and institutional culture to support challenge and grow Master Adaptive Learners.

Developments in medical education in response to the COVID-19 pandemic: A rapid BEME systematic review: BEME Guide No. 63.

BACKGROUND: The novel coronavirus disease (COVID-19) was declared a pandemic in March 2020. This rapid systematic review synthesised published reports of medical educational developments in response to the pandemic, considering descriptions of interventions, evaluation data and lessons learned. METHODS: The authors systematically searched four online databases and hand searched MedEdPublish up to 24 May 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias for included articles. Discrepancies were resolved by a third author. A descriptive synthesis and outcomes were reported. RESULTS: Forty-nine articles were included. The majority were from North America, Asia and Europe. Sixteen studies described Kirkpatrick's outcomes, with one study describing levels 1-3. A few papers were of exceptional quality, though the risk of bias framework generally revealed capricious reporting of underpinning theory, resources, setting, educational methods, and content. Key developments were pivoting educational delivery from classroom-based learning to virtual spaces, replacing clinical placement based learning with alternate approaches, and supporting direct patient contact with mitigated risk. Training for treating patients with COVID-19, service reconfiguration, assessment, well-being, faculty development, and admissions were all addressed, with the latter categories receiving the least attention. CONCLUSIONS: This review highlights several areas of educational response in the immediate aftermath of the COVID-19 pandemic and identifies a few articles of exceptional quality that can serve as models for future developments and educational reporting. There was often a lack of practical detail to support the educational community in enactment of novel interventions, as well as limited evaluation data. However, the range of options deployed offers much guidance for the medical education community moving forward and there was an indication that outcome data and greater detail will be reported in the future.

What do we mean by 'systematic' in health education systematic reviews and why it matters!

For anyone who reads the health education literature regularly, journal sections that focus on "reviews" are common, yet the use of the term "systematic" to describe these reviews is sporadic. Further, we believe this term is used in a manner in the field that does not accurately reflect the methodological implications of the term in this context. There are examples of "systematic" works that simply don't describe themselves in that way, despite a clear alignment with many of the principles of "systematic reviewing". Conversely, there are reviews that are clearly not systematic, yet describe themselves as such. In this piece, we discuss how this difficulty with methodological nomenclature has occurred and the distinct and important meaning of the term "systematic" in relation to health education reviews.

Twelve tips for undertaking a focused systematic review in medical education.

The exponential growth of the systematic review methodology within health has been mirrored within medical education, allowing large numbers of publications on a topic to be synthesized to guide researchers and teachers. The robust, transparent and reproducible search methodologies employed offer scholarly rigor. The scope and scale of many reviews in education have only been matched by the size of the commitment needed to complete them and occasional lack of utility of reports. As such, we have noticed a growth in reviews across journals in the field that have questions that are more focused in scope. The authors propose 12 tips for performing a focused review in the right settings for the right reasons and discuss why such "focused reviews" may be more beneficial in those circumstances. Focused reviews allow researchers to formulate answers to specific local issues that have explicit utility of findings. Such reviews are equipped to identify what works for specific groups in specific circumstances and even question how and why this may occur. An additional impact of a focused approach can be a rapid turnaround. This article explains the purpose and benefits of focused review and provides guidance on how to produce them.

Non-technical skills assessments in undergraduate medical education: A focused BEME systematic review: BEME Guide No. 54.

Consensus on how to assess non-technical skills is lacking. This systematic review aimed to evaluate the evidence regarding non-technical skills assessments in undergraduate medical education, to describe the tools used, learning outcomes and the validity, reliability and psychometrics of the instruments. A standardized search of online databases was conducted and consensus reached on included studies. Data extraction, quality assessment, and content analysis were conducted per Best Evidence in Medical Education guidelines. Nine papers met the inclusion criteria. Assessment methods broadly fell into three categories: simulated clinical scenarios, objective structured clinical examinations, and questionnaires or written assessments. Tools to assess non-technical skills were often developed locally, without reference to conceptual frameworks. Consequently, the tools were rarely validated, limiting dissemination and replication. There were clear themes in content and broad categories in methods of assessments employed. The quality of this evidence was poor due to lack of theoretical underpinning, with most assessments not part of normal process, but rather produced as a specific outcome measure for a teaching-based study. While the current literature forms a good starting position for educators developing materials, there is a need for future work to address these weaknesses as such tools are required across health education.