How do validity experts conceptualise argumentation? It's a rhetorical question.

INTRODUCTION: Health professions education (HPE) has adopted the conceptualization of validity as an argument. However, the theoretical and practical aspects of how validity arguments should be developed, used and evaluated in HPE have not been deeply explored. Articulating the argumentation theory undergirding validity and validation can help HPE better operationalise validity as an argument. To better understand this, the authors explored how HPE validity scholars conceptualise assessment validity arguments and argumentation, seeking to understand potential consequences of these views on validation practices. METHODS: The authors used critical case sampling to identify HPE assessment validity experts in three ways: (1) participation in a prominent validity research group, (2) appearing in a bibliometric study of HPE validity publications and (3) authorship of recent HPE validity literature. Qualitative semi-structured interviews were conducted with 16 experts in HPE assessment validity from four different countries. The authors used reflexive thematic analysis to develop themes relevant to their research question. RESULTS: The authors developed three themes grounded in participants' responses: (1) In theory, HPE validity is a social and situated argument. (2) In practice, the absence of audience and evaluation stymies the social nature of HPE validity. (3) Lack of validity argumentation creates and maintains power differentials within HPE. Participants articulated that current HPE validation practices are rooted in post-positivist epistemology when they should be situated (i.e. context-dependent), audience-centric and inclusive. DISCUSSION: When discussing validity argumentation in theory, participants' descriptions reflect an interpretivist lens for evaluation that is misaligned with real-world validity practices. This misalignment likely arises from HPE's adoption of "validity as an argument" as a slogan, without integrating theoretical and practical principles of argumentation theory.

Discursive (mis)alignments in internationalization: The case of International Medical Programmes.

PURPOSE: International Medical Programmes (IMPs) form a distinctive modality in medical education, with diverse student populations, English as a language of instruction and 'globalized' curricula. A lack of common understanding of IMPs' purposes and role in the medical education landscape triggers critiques. This study aims to document the effects of different discourses used to justify the purpose of IMPs. METHODS: We use a discourse analysis approach to explore the different ways in which the purposes of IMPs are constructed at the regulatory, institutional, and individual level, and how these discourses interact. The research situates in two IMPs, in the Netherlands and in Hungary. Key-informant interviews, policy documents, and scholarly literature form the archive. RESULTS: The purpose of IMPs is constructed discursively around three distinct narratives and associated practices: around serving the institutions that host them, around serving the (global) public interest, and around serving individual students. Co-existence and misalignments of these three discourses cause conflicting practices and confusion among stakeholders. CONCLUSIONS: This study illustrates how diverging perspectives on internationalization in medical education create tensions for learners and staff. Articulating a clear and explicit meaning to internationalization may reduce uncertainties, and may reinforce realistic expectations of what constitutes a good outcome.

Challenges, coping and support during student placement abroad: A qualitative study.

BACKGROUND: During placements abroad, healthcare students are confronted with different personal and professional challenges, related to participation in practice. This study investigates when and how students respond to such challenges, and which coping and support mechanisms students use to overcome these. METHODS: Twenty-five international students shared their experiences about physiotherapy placement in The Netherlands. Using a critical incident technique, we asked participants to recall events where participation was affected by an unforeseen situation, in or outside the clinic. Further, we explored students' strategies of seeking support within their social network to overcome individual challenges. Two researchers applied thematic analysis to the interview data, following an iterative approach. Team discussions supported focused direction of data collection and analysis, before conceptualizing results. RESULTS: Participants described a wide range of challenges. The scope and impact level of challenges varied widely, including intercultural differences, language barriers and inappropriate behaviour in the workplace, students' personal context and wellbeing. Mechanisms employed by students to overcome these challenges depended on the type of event (personal or professional), making purposeful use of their available network. CONCLUSION: Students involve clinical staff, peers, family and friends during placement abroad, to make deliberate use of their support network to overcome challenges in participation, whereas the academic network remains distant. Findings may help reflect on the roles and responsibilities of academic staff and other professionals involved with placements abroad. Healthcare programmes should ensure support before, during and after placement is within students' reach.

Pharmacist trainees narrow scope of interprofessional collaboration and communication in hospital practice.

Early curricular exposure to interprofessional education (IPE) is intended to acclimatize health professional trainees to shared-care in the practice settings they will ultimately join. However, IPE activities typically reside outside actual organizational and social systems in which interprofessional care is delivered. We aimed to explore how pharmacist trainees experience collaborator and communicator competency roles during team-based workplace-based learning. Participants maintained written diaries reflecting on interprofessional collaboration and communication during an eight-week hospital clerkship. Diary entries and transcripts from semi-structured follow-up interviews were analyzed from the social constructivist perspective using reflective thematic analysis. Participant accounts of on-ward activities represented most collaborator and communicator roles outlined in pharmacy and interprofessional competency frameworks, but were predominantly between the pharmacist trainee and physicians. Pharmacist trainees did not routinely engage with other health professions on a daily basis. Additionally, reported encounters with other team members were typically information exchanges and not episodes of authentic interdependent or shared care. Interactions were almost completely devoid of perceived interpersonal or role conflict. These findings offer insight into how pharmacist trainees perceive and develop competencies for team-based care. Further work is required to understand how such limited scope of interprofessional communication and collaboration might ultimately impair quality patient care.

Assessing trainee performance: ensuring learner control, supporting development, and maximizing assessment moments.

In this article, the authors provide practical guidance for frontline supervisors' efforts to assess trainee performance. They focus on three areas. First, they argue the importance of promoting learner control in the assessment process, noting that providing learners agency and control can shift the stakes of assessment from high to low and promote a safe environment that facilitates learning. Second, they posit that assessment should be used to support continued development by promoting a relational partnership between trainees and supervisors. This partnership allows supervisors to reinforce desirable aspects of performance, provide real-time support for deficient areas of performance, and sequence learning with the appropriate amount of scaffolding to push trainees from competence (what they can do alone) to capability (what they are able to do with support). Finally, they advocate the importance of optimizing the use of written comments and direct observation while also recognizing that performance is interdependent in efforts to maximize assessment moments.Conclusion: Using best practices in trainee assessment can help trainees take next steps in their development in a learner-centered partnership with clinical supervisors. What is Known: • Many pediatricians are asked to assess the performance of medical students and residents they work with but few have received formal training in assessment. What is New: • This article presents evidence-based best practices for assessing trainees, including giving trainees agency in the assessment process and focusing on helping trainees take next steps in their development.

How argumentation theory can inform assessment validity: A critical review.

INTRODUCTION: Many health professions education (HPE) scholars frame assessment validity as a form of argumentation in which interpretations and uses of assessment scores must be supported by evidence. However, what are purported to be validity arguments are often merely clusters of evidence without a guiding framework to evaluate, prioritise, or debate their merits. Argumentation theory is a field of study dedicated to understanding the production, analysis, and evaluation of arguments (spoken or written). The aim of this study is to describe argumentation theory, articulating the unique insights it can offer to HPE assessment, and presenting how different argumentation orientations can help reconceptualize the nature of validity in generative ways. METHODS: The authors followed a five-step critical review process consisting of iterative cycles of focusing, searching, appraising, sampling, and analysing the argumentation theory literature. The authors generated and synthesised a corpus of manuscripts on argumentation orientations deemed to be most applicable to HPE. RESULTS: We selected two argumentation orientations that we considered particularly constructive for informing HPE assessment validity: New rhetoric and informal logic. In new rhetoric, the goal of argumentation is to persuade, with a focus on an audience's values and standards. Informal logic centres on identifying, structuring, and evaluating arguments in real-world settings, with a variety of normative standards used to evaluate argument validity. DISCUSSION: Both new rhetoric and informal logic provide philosophical, theoretical, or practical groundings that can advance HPE validity argumentation. New rhetoric's foregrounding of audience aligns with HPE's social imperative to be accountable to specific stakeholders such as the public and learners. Informal logic provides tools for identifying and structuring validity arguments for analysis and evaluation.

Putting self-regulated learning in context: Integrating self-, co-, and socially shared regulation of learning.

Processes involved in the regulation of learning have been researched for decades, because of its impact on academic and workplace performance. In fact, self-regulated learning is the focus of countless studies in health professions education and higher education in general. While we will always need competent individuals who are able to regulate their own learning, developments in healthcare require a shift from a focus on the individual to the collective: collaboration within and between healthcare teams is at the heart of high-quality patient care. Concepts of collaborative learning and collective competence challenge commonly held conceptualisations of regulatory learning and call for a focus on the social embeddedness of regulatory learning and processes regulating the learning of the collective. Therefore, this article questions the alignment of current conceptualisations of regulation of learning with demands for collaboration in current healthcare. We explore different conceptualisations of regulation of learning (self-, co-, and socially shared regulation of learning), and elaborate on how the integration of these conceptualisations adds to our understanding of regulatory learning in healthcare settings. Building on these insights, we furthermore suggest ways forward for research and educational practice.

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.

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

PURPOSE: Clinical supervisors acknowledge that they sometimes allow trainees to fail for educational purposes. What remains unknown is how supervisors decide whether to allow failure in a specific instance. Given the high stakes nature of these decisions, such knowledge is necessary to inform conversations about this educationally powerful and clinically delicate phenomenon. MATERIALS AND METHODS: 19 supervisors participated in semi-structured interviews to explore how they view their decision to allow failure in clinical training. Following constructivist grounded theory methodology, the iteratively collected data and analysis were informed by theoretical sampling. RESULTS: Recalling instances when they considered allowing residents to fail for educational purposes, supervisors characterized these as intuitive, in-the-moment decisions. In their post hoc reflections, they could articulate four factors that they believed influenced these decisions: patient, supervisor, trainee, and environmental factors. While patient factors were reported as primary, the factors appear to interact in dynamic and nonlinear ways, such that supervisory decisions about allowing failure may not be predictable from one situation to the next. CONCLUSIONS: Clinical supervisors make many decisions in the moment, and allowing resident failure appears to be one of them. Upon reflection, supervisors understand their decisions to be shaped by recurring factors in the clinical training environment. The complex interplay among these factors renders predicting such decisions difficult, if not impossible. However, having a language for these dynamic factors can support clinical educators to have meaningful discussions about this high-stakes educational strategy.

How medical students co-regulate their learning in clinical clerkships: a social network study.

BACKGROUND: Self-regulated learning is a key competence to engage in lifelong learning. Research increasingly acknowledges that medical students in clerkships need others to regulate their learning. The concept of "co-regulated learning" captures this act of regulating one's learning by interacting with others. To effectively cultivate such skills in students, we need to increase our understanding of co-regulated learning. This study aimed to identify the purposes for which students in different phases of clinical training engage others in their networks to regulate their learning. METHODS: In this social network study, we administered a questionnaire to 403 medical students during clinical clerkships (65.5% response rate). The questionnaire probed into the composition of students' co-regulatory networks and the purpose for which they engaged others in specified self-regulated learning activities. We calculated the proportion of students that engaged others in their networks for each regulatory activity. Additionally, we conducted ANOVAs to examine whether first-, second-, and third-year students differed in how they used their networks to support self-regulation. RESULTS: Students used others within their co-regulatory networks to support a range of self-regulated learning activities. Whom students engaged, and the purpose of engagement, seemed to shift as students progressed through clinical training. Over time, the proportion of students engaging workplace supervisors to discuss learning goals, learning strategies, self-reflections and self-evaluations increased, whereas the proportion of students engaging peers to discuss learning strategies and how to work on learning goals in the workplace decreased. Of all purposes for which students engaged others measured, discussing self-reflections and self-evaluations were consistently among the ones most frequently mentioned. CONCLUSIONS: Results reinforce the notion that medical students' regulation of learning is grounded in social interactions within co-regulatory networks students construct during clerkships. Findings elucidate the extent to which students enact self-regulatory learning within their co-regulatory networks and how their co-regulatory learning behaviors develop over time. Explicating the relevance of interactions within co-regulatory networks might help students and supervisors to purposefully engage in meaningful co-regulatory interactions. Additionally, co-regulatory interactions may assist students in regulating their learning in clinical workplaces as well as in honing their self-regulated learning skills.

Mentoring is in the 'I' of the beholder: supporting mentors in reflecting on their actual and preferred way of mentoring.

BACKGROUND: An important strategy to support the professional development of mentors in health professions education is to encourage critical reflection on what they do, why they do it, and how they do it. Not only the 'how' of mentoring should be covered, but also the implicit knowledge and beliefs fundamental to the mentoring practice (a mentor's personal interpretative framework). This study analyzed the extent to which mentors perceive a difference between how they actually mentor and how they prefer to mentor. METHODS: The MERIT (MEntor Reflection InstrumenT) survey (distributed in 2020, N = 228), was used to ask mentors about the how, what, and why of their mentoring in two response modes: (1) regarding their actual mentoring practice and (2) regarding their preferred mentoring practice. With an analysis of covariance, it was explored whether potential discrepancies between these responses were influenced by experience, profession of the mentor, and curriculum-bound assessment requirements. RESULTS: The averaged total MERIT score and averaged scores for the subscales 'Supporting Personal Development' and 'Monitoring Performance' were significantly higher for preferred than for actual mentoring. In addition, mentors' experience interacted significantly with these scores, such that the difference between actual and preferred scores became smaller with more years of experience. CONCLUSIONS: Mentors can reflect on their actual and preferred approach to mentoring. This analysis and the potential discrepancy between actual and preferred mentoring can serve as input for individual professional development trajectories.

Incentives for clinical teachers: On why their complex influences should lead us to proceed with caution.

INTRODUCTION: When medical education programs have difficulties recruiting or retaining clinical teachers, they often introduce incentives to help improve motivation. Previous research, however, has shown incentives can unfortunately have unintended consequences. When and why that is the case in the context of incentivizing clinical teachers remains unclear. The purposes of this study, therefore, were to understand what values and motivations influence teaching decisions; and to delve deeper into how teaching incentives have been perceived. METHODS: An interpretive description methodology was used to improve understanding of the development and delivery of teaching incentives. A purposeful sampling strategy identified a heterogenous sample of clinical faculty teaching in undergraduate and postgraduate contexts. Sixteen semi-structured interviews were conducted and transcripts were analyzed using an iterative process to develop a thematic structure that accounts for general trends and individual variations. RESULTS: Clinicians articulated interrelated and dynamic personal and environmental factors that had linear, dual-edged and inverted U-shaped impacts on their motivations towards teaching. Barriers were frequently rationalized away, but cumulative barriers often led to teaching attrition. Clinical teachers were motivated when they felt valued and connected to their learners, peers, leadership, and/or the medical education community. While incentives aimed at producing these connections could be perceived as supportive, they could also negatively impact motivation if they were impersonal, inequitable, inefficient, or poorly framed. DISCUSSION/CONCLUSION: These findings reinforce the literature suggesting that it is necessary to proceed with caution when labeling any particular factor as a motivator or barrier to teaching. They take us deeper, however, towards understanding how and why clinical teachers' perceptions are unique, dynamic and fluid. Incentive schemes can be beneficial for teacher recruitment and retention, but must be designed with nuance that takes into account what makes clinicians feel valued if the strategy is to do more good than harm.

Team member expectations of trainee communicator and collaborator competencies - so shines a good deed in a weary world?

BACKGROUND: Workplace-based assessment may be further optimized by drawing upon the perspectives of multiple assessors, including those outside the trainee's discipline. Interprofessional competencies like communication and collaboration are often considered suitable for team input. AIM: We sought to characterize multidisciplinary expectations of communicator and collaborator competency roles. METHODS: We adopted a constructivist grounded theory approach to explore perspectives of multidisciplinary team members on a clinical teaching unit. In semi-structured interviews, participants described expectations for competent collaboration and communication of trainees outside their own discipline. Data were analyzed to identify recurring themes, underlying concepts and their interactions using constant comparison. RESULTS: Three main underlying perspectives influenced interprofessional characterization of competent communication and collaboration: (1) general expectations of best practice; (2) specific expectations of supportive practice; and (3) perceived commitment to teaching practice. However, participants seemingly judged trainees outside their discipline according to how competencies were exercised to advance their own professional patient care decision-making, with minimal attention to the trainee's specific skillset demonstrated. CONCLUSION: While team members expressed commitment to supporting interprofessional competency development of trainees outside their discipline, service-oriented judgement of performance loomed large. The potential impact on the credibility of multidisciplinary sources for workplace-based assessment requires consideration.

Can concept mapping support the quality of reflections made by undergraduate medical students? A mixed method study.

BACKGROUND: Students perceive reflective writing as difficult. Concept mapping may be an alternative format for reflection, which provides support while allowing students to freely shape their thoughts. We examined (1) the quality of reflection in reflective concept maps created by first-year medical students and (2) students' perceptions about concept mapping as a tool for reflection. METHODS: Mixed-method study conducted within the medical curriculum of Maastricht University, The Netherlands, consisting of: (1) Analysis of the quality of reflection in 245 reflective concept maps created by 40 first-year students. Reflection quality was analysed by assessing focus of reflection (technical/practical/sensitising) and depth of reflection (description/justification/critique/discussion). (2) Semi-structured interviews with 22 students to explore perceived effectiveness of reflective concept mapping. RESULTS: Depth of reflection reached at least the level of critique in 82% of maps. Three factors appeared to affect the perceived effectiveness of concept mapping for reflection: (1) reflective concept map structure; (2) alertness to meaningful experiences in practice and (3) learning by doing. CONCLUSION: These results yielded supportive evidence for concept mapping as a useful technique to teach novice learners the basics of effective reflection. Meaningful implementation requires a delicate balance between providing a supportive structure and allowing flexibility for the student.

Initiation of student participation in practice: An audio diary study of international clinical placements.

BACKGROUND: Differences in professional practice might hinder initiation of student participation during international placements, and thereby limit workplace learning. This study explores how healthcare students overcome differences in professional practice during initiation of international placements. METHODS: Twelve first-year physiotherapy students recorded individual audio diaries during the first month of international clinical placement. Recordings were transcribed, anonymized, and analyzed following a template analysis approach. Team discussions focused on thematic interpretation of results. RESULTS: Students described tackling differences in professional practice via ongoing negotiations of practice between them, local professionals, and peers. Three themes were identified as the focus of students' orientation and adjustment efforts: professional practice, educational context, and individual approaches to learning. Healthcare students' initiation during international placements involved a cyclical process of orientation and adjustment, supported by active participation, professional dialogue, and self-regulated learning strategies. CONCLUSIONS: Initiation of student participation during international placements can be supported by establishing a continuous dialogue between student and healthcare professionals. This dialogue helps align mutual expectations regarding scope of practice, and increase understanding of professional and educational practices. Better understanding, in turn, creates trust and favors meaningful students' contribution to practice and patient care.

MERIT: a mentor reflection instrument for identifying the personal interpretative framework.

BACKGROUND: Essential to the professional development of mentors is making explicit and critically challenging the knowledge and beliefs underpinning their mentoring practice. This paper reports on the development of a survey instrument called MERIT, MEntor Reflection InstrumenT, which was designed to support mentors' systematic reflection on the how, what and why of their practice. METHODS: In 2019, a twenty-item survey instrument was developed and piloted. Initial validation data (N = 228) were collected by distributing the survey through the authors' network. An exploratory factor analysis (EFA) was conducted and internal consistency reliability coefficients were calculated. RESULTS: The Principal Axis EFA with Direct Oblimin rotation (Delta = 0) resulted in four factors: 1) supporting personal development, 2) modelling professional development, 3) fostering autonomy, and 4) monitoring performance. The four factors explained 43% of the total variance of item scores. The Cronbach's alphas for the subscale scores were between .42 and .75. CONCLUSIONS: The MERIT can help mentors reflect on their beliefs and professional knowhow. These reflections can serve as input for the faculty development initiatives mentors undertake, which may ultimately improve their knowledge and skills as a mentor.

Beyond the self: The role of co-regulation in medical students' self-regulated learning.

CONTEXT: Medical students are expected to self-regulate their learning within complex and unpredictable clinical learning environments. Research increasingly focuses on the effects of social interactions on the development of self-regulation in workplace settings, a notion embodied within the concept of co-regulated learning (CRL). Creating workplace learning environments that effectively foster lifelong self-regulated learning (SRL) requires a deeper understanding of the relationship between CRL and SRL. The aim of this study was therefore to explore medical students' perceptions of CRL in clinical clerkships and its perceived impact on the development of their SRL. METHODS: We conducted semi-structured interviews with 11 purposively sampled medical students enrolled in clinical clerkships at one undergraduate competency-based medical school. Data collection and analysis were conducted iteratively, informed by principles of constructivist grounded theory. Data analysis followed stages of open, axial and selective coding, which enabled us to conceptualise how co-regulation influences the development of students' self-regulation. RESULTS: Data revealed three interrelated shifts in CRL and SRL as students progressed through clerkships. First, students' CRL shifted from a focus on peers to co-regulation with clinician role models. Second, self-regulated behaviour shifted from being externally driven to being internally driven. Last, self-regulation shifted from a task-oriented approach towards a more comprehensive approach focusing on professional competence and identity formation. Students indicated that if they felt able to confidently and proactively self-regulate their learning, the threshold for engaging others in meaningful CRL seemed to be lowered, enhancing further development of SRL skills. CONCLUSIONS: Findings from the current study emphasise the notion that SRL and its development are grounded in CRL in clinical settings. To optimally support the development of students' SRL, we need to focus on facilitating and organising learners' engagement in CRL from the start of the medical curriculum.

Learning in the workplace: Use of informal feedback cues in doctor-patient communication.

OBJECTIVES: We expect physicians to be lifelong learners. Participation in clinical practice is an important potential source of that learning. To support physicians in this process, a better understanding of how they learn in clinical practice is necessary. This study investigates how physicians recognise and use informal feedback from interactions with patients in outpatient settings as learning cues to adjust their communication behaviours in daily practice. METHODS: To understand physicians' use of informal feedback, we combined non-participant observations with semi-structured interviews. We enrolled 10 respiratory physicians and observed 100 physician-patient interactions at two teaching hospitals in the Netherlands. Data collection and analysis were performed iteratively according to the principles of constructivist grounded theory. RESULTS: Following stages of open, axial and selective coding, we were able to conceptualise how physicians use cues to reflect on and adjust their communication. In addition to vast variations within and across patient encounters, we observed recurring adjustments in physicians' communication behaviours in response to specific informal feedback cues. Physicians recognised and used these cues to self-monitor communication performance. They had established 'communication repertoires' based on multiple patient interactions, which many saw as learning opportunities contributing to the development of expertise. Our findings, however, show differences in physicians' individual levels of sensitivity in recognising and using learning opportunities in daily practice, which were further influenced by contextual, personal and interpersonal factors. Whereas some described themselves as having little inclination to change, others used critical incidents to fine-tune their communication repertoires, and yet others constantly reshaped them, seeking learning opportunities in their daily work. CONCLUSIONS: There is large variation in how physicians use learning cues from daily practice. To enhance learning in and from daily practice, we propose turning workplace learning into a collaborative effort with the aim of increasing awareness and the use of informal performance-relevant feedback.

Perceptions of people with respiratory problems on physician performance evaluation-A qualitative study.

BACKGROUND: Despite increasing calls for patient and public involvement in health-care quality improvement, the question of how patient evaluations can contribute to physician learning and performance assessment has received scant attention. OBJECTIVE: The objective of this study was to explore, amid calls for patient involvement in quality assurance, patients' perspectives on their role in the evaluation of physician performance and to support physicians' learning and decision making on professional competence. DESIGN: A qualitative study based on semi-structured interviews. SETTING AND PARTICIPANTS: The study took place in a secondary care setting in the Netherlands. The authors selected 25 patients from two Dutch hospitals and through the Dutch Lung Foundation, using purposive sampling. METHODS: Data were analysed according to the principles of template analysis, based on an a priori coding framework developed from the literature about patient empowerment, feedback and performance assessment. RESULTS: The analysis unearthed three predominant patient perspectives: the proactive perspective, the restrained perspective and the outsider perspective. These perspectives differed in terms of perceived power dynamics within the doctor-patient relationship, patients' perceived ability, and willingness to provide feedback and evaluate their physician's performance. Patients' perspectives thus affected the role patients envisaged for themselves in evaluating physician performance. DISCUSSION AND CONCLUSION: Although not all patients are equally suitable or willing to be involved, patients can play a role in evaluating physician performance and continuing training through formative approaches. To involve patients successfully, it is imperative to distinguish between different patient perspectives and empower patients by ensuring a safe environment for feedback.

Workplace-Based Assessment in Cross-Border Health Professional Education.

Construct: The globalization of healthcare has been accentuated by the export of health professional curricula overseas. Yet intact translation of pedagogies and practices devised in one cultural setting may not be possible or necessarily appropriate for alternate environments. Purposeful examination of workplace learning is necessary to understand how the source or "home" program may need adapting in the distributed or "host" setting. Background: Strategies to optimize cross-border medical education partnerships have been largely focused on elements of campus-based learning. Determining how host clinical supervisors approach assessment in experiential settings within a different culture and uphold the standards of home programs is relevant given the influence of context on trainees' demonstrated competencies. In this mixed-methods study, we sought to explore assessor judgments of student workplace-based performance made by preceptors sharing a pharmacy curriculum in Canada and Qatar. Approach: Using modified Delphi consensus technique, we asked clinical supervisors in Canada (n = 18) and in Qatar (n = 14) to categorize trainee performance as described in 16 student vignettes. The proportion of ratings for three levels of expectation (exceeds, meets, or below) was calculated and within-country group consensus achieved if the level of agreement reached 80%. Between-country group comparisons were measured using a chi-square statistic. We then conducted follow-up semi-structured interviews to gain further perspectives and clarify assessor rationale. Transcripts were analyzed using thematic content analysis. Results: The threshold for between-country group differences in assessor impressions was met for only two of the 16 student vignettes. Compared to Canadian clinical supervisors, relatively more preceptors in Qatar judged one described student as meets rather than exceeds expectations and one as meets rather than falls below expectations. Analysis of follow-up interviews exploring how culture may inform variations in assessor judgments identified themes associated with the profession, organization, learner, and supervisor performance theories but not their particular geographic context. Clinical supervisors in both countries were largely aligned in expectations of student knowledge, skills, and behaviors demonstrated in patient care and multidisciplinary team interactions. Conclusions: Our study demonstrated that variation in student assessment was more frequent among clinical supervisors within the same national context than any differences identified between the two countries. In these program settings, national sociocultural norms did not predict global assessor impressions or competency-specific judgments; instead, professional and organizational cultures were more likely to inform student characterizations of performance in workplace-based settings. Further study situated within the specific experiential learning contexts of cross-border health professional curricula is assuredly warranted.