The views of parents and carers on managing acute otitis media in urban Aboriginal and Torres Strait Islander children: a qualitative study.

OBJECTIVES: To explore the views of parents and carers regarding the management of acute otitis media in urban Aboriginal and Torres Strait Islander children who are at low risk of complications living in urban communities. STUDY DESIGN: Qualitative study; semi-structured interviews and short telephone survey. SETTING, PARTICIPANTS: Interviews: purposive sample of parents and carers of urban Aboriginal and Torres Strait Islander children (18 months - 16 years old) screened in Aboriginal medical services in Queensland, New South Wales, and Canberra for the WATCH study, a randomised controlled trial that compared immediate antibiotic therapy with watchful waiting for Aboriginal and Torres Strait Islander children with acute otitis media. SURVEY: parents and carers recruited for the WATCH trial who had completed week two WATCH surveys. RESULTS: We interviewed twenty-two parents and carers, including ten who had declined participation in or whose children were ineligible for the WATCH trial. Some interviewees preferred antibiotics for managing acute otitis media, others preferred watchful waiting, expressing concerns about side effects and reduced efficacy with overuse of antibiotics. Factors that influenced this preference included the severity, duration, and recurrence of infection, and knowledge about management gained during the trial and from personal and often multigenerational experience of ear disease. Participants highlighted the importance of shared decision making by parents and carers and their doctors. Parents and carers of 165 of 262 WATCH participants completed telephone surveys (63%); 81 were undecided about whether antibiotics should always be used for treating acute otitis media. Open-ended responses indicated that antibiotic use should be determined by clinical need, support for general practitioners' decisions, and the view that some general practitioners prescribed antibiotics too often. CONCLUSIONS: Parents and carers are key partners in managing acute otitis media in urban Aboriginal and Torres Strait Islander children. Our findings support shared decision making informed by the experience of parents and carers, which could also lead to reduced antibiotic use for managing acute otitis media.

Longitudinal exploration of students' identity formation during the transition from pre-clinical to clinical training using research poetry.

BACKGROUND: Transitions are critical periods that can lead to growth and, or, distress. Transitions are a sociocultural process, yet most approaches to transitions in practice and research do not explore the social or developmental aspects of entering a new training phase. Wenger reminds us that identity development is crucial when newcomers navigate change. In this paper, we use Wenger's modes of identification: engagement, imagination and alignment to explore students' identity development (as a student and professional) during the transition from pre-clinical to clinical training. METHODS: We enrolled nine 2nd-year medical students who generated 61 entries comprising audio diary (or typed) reflections over 9 months (starting 3 months before clinical clerkships began) and interviewed them twice. We used research poems (transcripts reframed as poetry) to help construct a meaningful, emotive elicitation of our longitudinal data and analysed data using sensitising concepts from Wenger's modes of identification. RESULTS: Students described their transition as a journey filled with positive and negative emotions and uncertainty about their current and future careers. Students navigated the transition using three mechanisms: (1) becoming more engaged through taking charge, (2) shaping their image of self through engagement and finding role models and (3) learning to flexibly adapt to clerkship norms by managing expectations and adopting a journey mindset. CONCLUSIONS: We successfully narrated students' identity formation during their transition to clinical training. We learned that students became more engaged over time by learning to take charge. They shaped their image of self by engaging in team activities and reflecting on role models. They learnt to adapt flexibly to clerkship norms by managing expectations and adopting a journey mindset. We suggest that institutions provide a safe opportunity for medical students to reflect, allowing students' transition periods to be lived, reflected on and supported.

Educators as Judges: Applying Judicial Decision-Making Principles to High-Stakes Education Assessment Decisions.

Phenomenon: Programmatic assessment and competency-based education have highlighted the need to make robust high-stakes assessment decisions on learner performance from evidence of varying types and quality. Without guidance, lengthy deliberations by decision makers and competence committees can end inconclusively with unresolved concerns. These decisional dilemmas are heightened by their potential impacts. For learners, erroneous decisions may lead to an unjustified exit from a long-desired career, or premature promotion to clinical responsibilities. For educators, there is the risk of wrongful decision-making, leading to successful appeals and mistrust. For communities, ill-prepared graduates risk the quality and safety of care. Approaches such as psychometric analyses are limited when decision-makers are faced with seemingly contradictory qualitative and quantitative evidence about the same individual. Expertise in using such evidence to make fair and defensible decisions is well established in judicial practice but is yet to be practically applied to assessment decision-making. Approach: Through interdisciplinary exchange, we investigated medical education and judicial perspectives on decision-making to explore whether principles of decision-making in law could be applied to educational assessment decision-making. Using Dialogic Inquiry, an iterative process of scholarly and mutual critique, we contrasted assessment decision making in medical education with judicial practice to identify key principles in judicial decision-making relevant to educational assessment decisions. We developed vignettes about common but problematic high-stakes decision-making scenarios to test how these principles could apply. Findings: Over 14 sessions, we identified, described, and applied four principles for fair, reasonable, and transparent assessment decision-making. These were: The person whose interests are affected has a right to know the case against them, and to be heard.Reasons for the decision should be given.Rules should be transparent and consistently applied.Like cases should be treated alike and unlike cases treated differently.Reflecting our dialogic process, we report findings by separately presenting the medical educator and judicial perspectives, followed by a synthesis describing a preferred approach to decision-making in three vignettes. Insights: Judicial principles remind educators to consider both sides of arguments, to be consistent, and to demonstrate transparency when making assessment decisions. Dialogic Inquiry is a useful approach for generating interdisciplinary insights on challenges in medical education by critiquing difference (e.g., the meaning of objectivity) and achieving synthesis where possible (e.g., fairness is not equal treatment of all cases). Our principles and exemplars provide groundwork for promoting good practice and furthering assessment research toward fairer and more robust decisions that will assist learning.

Becoming Agents of Change: Contextual Influences on Medical Educator Professionalization and Practice in a LMIC Context.

Medical educators are particularly needed in Low- and Middle-Income Countries (LMIC), where medical schools have grown rapidly in size, number, and global outlook in response to persistent health workforce shortages and increased expectations of quality care. Educator development is thus the focus of many LMIC programs initiated by universities and governments of high income countries. While signs of medical educator professionalization such as postgraduate qualifications, specialized units, and professional associations have emerged in LMIC, whether these relate to programs originating from outside LMIC contexts is unknown. This study investigated the contextual influences on the long-term impact of an international faculty development program a decade after its delivery in a LMIC context - Vietnam.Ten years after an international aid program to develop clinical skills teaching expertise in Vietnam, we conducted in-depth qualitative interviews with eight medical educators from all eight participating medical schools. Selected for their leadership potential, each participant had completed the Maastricht Masters in Health Professions Education during the program. Interview transcripts underwent thematic analysis, using the Theory of Practice Architectures as a conceptual lens to highlight the contextual influences on professional practice.Four themes were identified: Careers and Practices before, during, and after the program, Unrecognized and Unseen practice, Structural Restraints on individual advancement and collective activity, and the Cultivation of Connections through social traditions. Participants reported being in well-established teaching delivery roles. However, the absence of professionalizing discourses and material resources meant that practice was restricted and determined by institutional leadership and individuals' adaptations.Informed by the theory of practice architectures, we found that change in medical education practice will falter in contexts that lack supporting discursive, material-economic, and socio-political arrangements. While there were emerging signs of individual agency, the momentum of change was not sustained and perhaps unapparent to Western framings of educational leadership. Practice architectures offers a framework for identifying the contextual features which influence practice, from which to design and deliver sustainable and impactful interventions, and to advance context-relevant evaluation and research. Our findings suggest that faculty development delivered across diverse contexts, such as in distributed or transnational medical programs, may have more effect if informed by a practice architectures analysis of each context.

"You're actually part of the team": a qualitative study of a novel transitional role from medical student to doctor.

BACKGROUND: Optimizing transitions from final year of medical school and into first post graduate year has important implications for students, patients and the health care system. Student experiences during novel transitional roles can provide insights into potential opportunities for final year curricula. We explored the experiences of medical students in a novel transitional role and their ability to continue learning whilst working as part of a medical team. METHODS: Novel transitional role for final year medical students were created in partnership by medical schools and state health departments in 2020 in response to the COVID-19 pandemic and the need for a medical surge workforce. Final year medical students from an undergraduate entry medical school were employed as Assistants in Medicine (AiMs) in urban and regional hospitals. A qualitative study with semi-structured interviews at two time points was used to obtain experiences of the role from 26 AiMs. Transcripts were analyzed using deductive thematic analysis with Activity theory as a conceptual lens. RESULTS: This unique role was defined by the objective of supporting the hospital team. Experiential learning opportunities in patient management were optimized when AiMs had opportunities to contribute meaningfully. Team structure and access to the key instrument, the electronic medical record, enabled participants to contribute meaningfully, whilst contractual arrangements and payments formalized the obligations to contribute. CONCLUSIONS: The experiential nature of the role was facilitated by organizational factors. Structuring teams to involve a dedicated medical assistant position with specific duties and access to the electronic medical record sufficient to complete duties are key to successful transitional roles. Both should be considered when designing transitional roles as placements for final year medical students.

Welcomeness for people with substance use disorders to general practice: a qualitative study.

BACKGROUND: Good primary care for people with substance use disorders (SUDs) is crucial given the high prevalence of SUDs and overdose deaths. OBJECTIVE: To explore general practice care for people with a history of SUDs from the perspectives of women involved with the criminal justice system. METHODS: Qualitative interview study with pre- and postrelease interviews, undertaken in Australian prisons and community settings. We utilized thematic analysis informed by constructivist grounded theory. RESULTS: We undertook 65 interviews with 39 women. Access to and experience of general practitioner (GP) care was affected by perceived welcomeness, decisions around disclosure, and consultation experiences related to medication prescription. Participants reported that they were not as welcome as other patients, welcome could be conditional on not disclosing SUDs or only requesting unrelated healthcare, and GPs did not always differentiate between past and current drug use. Participants perceived difficulty finding general practices where the potential benefit of disclosing SUDs outweighed the risks of stigmatized reactions and lack of GP skills and interest. Participants did not always recognize that care beyond physical health could occur in general practice. The pejorative implications of labelling patients as "doctor shoppers" were challenged by participants, as they considered it could be necessary to attend multiple GPs to find a welcoming practice. CONCLUSIONS: People with histories of SUDs do not uniformly experience welcomeness in general practice, perpetuating poor engagement in healthcare and poor outcomes related to SUDs. Programmes targeting prescription drug misuse through general practice should also promote welcomeness for people with SUDs.

Chatbot-mediated learning of cardiac auscultation.

Previous research suggested cardiac auscultation is underdeveloped in physicians-in-training. Developing proficiency requires wide exposure to signs, practice and feedback, which may not regularly occur in clinical environments. Our novel pilot study using a mixed-methods approach (n = 9) suggests chatbot-mediated learning of cardiac auscultation is accessible and possesses unique advantages, including immediate feedback, helping in the management of cognitive overload and facilitating deliberate practice.

The socioemotional challenges and consequences for caregivers of Aboriginal and Torres Strait Islander children with otitis media: A qualitative study.

INTRODUCTION: Living with ear disease can have extensive impacts on physical, emotional and social well-being. This study explored otitis media (OM) and its management from the perspective of caregivers of Aboriginal and Torres Strait Islander children. METHODS: Semi-structured interviews were conducted from 2015 to 2020 with caregivers of Aboriginal and Torres Strait Islander children with OM. Thematic analysis of transcripts was undertaken using a constructivist grounded theory approach through the leadership and the cultural lens of an Aboriginal community-based researcher. RESULTS: Caregivers described OM as having profound impacts on their child's physical, developmental, and emotional well-being, with long waits for specialist treatment contributing to extra strain on families. Children's well-being suffered when OM was mistaken for poor behaviour and children were punished, with caregivers subsequently experiencing strong feelings of guilt. Concerns were conveyed about the social implications of having a sick child. The variable nature of OM symptoms meant that caregivers had to monitor closely for sequelae and advocate for appropriate treatment. Success in navigating the diagnosis and treatment of OM can be strongly impacted by the relationship between caregivers and health professionals and the perceived access to respectful, collaborative and informative healthcare. CONCLUSION: OM may have substantial social and emotional consequences for children and their caregivers. A holistic understanding of the way in which OM impacts multiple facets of health and well-being, as well as recognition of challenges in accessing proper care and treatment, will aid families managing OM and its sequelae. PATIENT OR PUBLIC CONTRIBUTION: Governing boards, managers, staff and community members from five Australian Aboriginal Medical Services were involved in the approval, management and conduct of this study and the wider clinical trials. The caregivers of Aboriginal and Torres Strait Islander patients at these services informed the interview study and guided its purpose.

Supporting medical students to support peers: a qualitative interview study.

BACKGROUND: Students may be the first to recognise and respond to psychological distress in other students. Peer support could overcome medical student reluctance to seek help despite their high rates of mental ill-health. Yet, despite the adoption of peer support programs, there is little evidence of impact on students. Peer support programs may assume that medical students accept and view peer support positively. We explored these assumptions by asking students about their experiences and views on peer support. METHODS: Qualitative semi-structured interviews exploring peer support experiences and views on peer support were conducted with ten medical students at two contrasting medical schools. Informed by a constructivist stance, interview transcripts underwent thematic analysis. RESULTS: Three groups of themes were identified: participants' experiences of peer support encounters, concerns about providing support, and views on students' roles in peer support. Participants readily recalled signs of peer distress. Encounters were ad hoc, informal, and occurred within relationships based on friendship or by being co-located in the same classes or placements. Concerns about initiating and offering support included lack of expertise, maintaining confidentiality, stigma from a mental health diagnosis, and unclear role boundaries, with implications for acceptance of student roles in peer support. CONCLUSIONS: Our study emphasised the centrality of social relationships in enabling or discouraging peer support. Relationships developed during medical studies may anticipate the collegial relationships between medical professionals. Nevertheless, only some students are willing to undertake peer support roles. We suggest different strategies for promoting informal peer support that can be offered by any student, to those promoting formal support roles for selected students. Future research focusing on the impact for both the students who receive, and on the students who provide peer support is called for.

The change from UMAT to UCAT for undergraduate medical school applicants: impact on selection outcomes.

OBJECTIVES: To assess whether the change from the Undergraduate Medical and Health Sciences Admissions Test (UMAT; 1991-2019) to the University Clinical Aptitude Test (UCAT) for the 2020 New South Wales undergraduate medical degree intake was associated with changes in the impact of sex, socio-economic status and remoteness of residence, and professional coaching upon selection for interview. DESIGN, SETTING, PARTICIPANTS: Cross-sectional study of applicants for the three NSW undergraduate medical programs for entry in 2019 (4114 applicants) or 2020 (4270); 703 people applied for both intakes. Applicants selected for interview were surveyed about whether they had received professional coaching for the selection test. MAIN OUTCOME MEASURES: Scores on the three sections of the UMAT (2019 entry cohort) and the five subtests of the UCAT (2020 entry); total UMAT and UCAT scores. RESULTS: Mean scores for UMAT 1 and 3 and for all four UCAT cognitive subtests were higher for men than women; the differences were statistically significant after adjusting for age, socio-economic status, and remoteness. The effect size for sex was 0.24 (95% CI, 0.18-0.30) for UMAT total score, 0.38 (95% CI, 0.32-0.44) for UCAT total score. For the 2020 intake, 2303 of 4270 applicants (53.9%) and 476 of 1074 interviewees (44.3%) were women. The effect size for socio-economic status was 0.47 (95% CI, 0.39-0.54) for UMAT, 0.43 (95% CI, 0.35-0.50) for UCAT total score; the effect size for remoteness was 0.54 (95% CI, 0.45-0.63) for UMAT, 0.48 (95% CI, 0.39-0.58) for UCAT total score. The impact of professional coaching on UCAT performance was not statistically significant among those accepted for interview. CONCLUSIONS: Women and people from areas outside major cities or of lower socio-economic status perform less well on the UCAT than other applicants. Reviewing the test and applicant quotas may be needed to achieve selection equity.

Students' social networks are diverse, dynamic and deliberate when transitioning to clinical training.

CONTEXT: Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre-clinical to clinical training. METHODS: Eight medical students completed a social network map during a semi-structured interview within two weeks of beginning their clinical clerkships (T0 ) and then again four months later (T1 ). They indicated meaningful interactions that influenced their transition from pre-clinical to clinical training and discussed how these relationshipsimpacted their transition. We conducted mixed-methods analysis on this data. RESULTS: At T0 , eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T1 . People from within and beyond the clinical space made up participants' social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near-peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance). CONCLUSIONS: This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students' social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions.

A patient expectations questionnaire for determining criteria for entrustment decisions.

INTRODUCTION: To train health professionals for patient-centered care, patient engagement in medical curriculum development and assessment is widely recommended. But there are few published methods on how to consult with patients effectively, particularly when creating entrustable professional activities (EPAs). In this mixed-method study, we developed a questionnaire for facilitating patient input when developing EPA assessment criteria. METHODS: We developed a questionnaire for documenting patient expectations of their doctors which included: patient interviews to identify questionnaire items, expert validation, cognitive interviews with respondents, and finally, pilot testing. For the pilot testing, 87 participants with a variety of health problems from medical/surgical wards and outpatient clinics at a tertiary hospital were recruited. The final questionnaire included open-ended and ranking-style questions. RESULTS: Using the questionnaire, patients could identify their key expectations of their doctors when managing their current medical problem. Most patients wrote clear, brief free-text responses directly applicable to EPA descriptors that were time-efficient to analyze. CONCLUSIONS: The questionnaire is a feasible method of recording patient expectations, enabling educators to consult with and include patient perspectives when developing criteria for entrustment decisions in a diverse range of clinical contexts.

Advancing careers in medical education: 'Practice architectures' for success in a resource-constrained setting.

INTRODUCTION: Advancement of careers in medical education remains a challenge around the world and is under-researched in resource-constrained contexts. Using the Theory of Practice Architectures (TPA) as a conceptual lens, we investigated the emergence and subsequent development of medical education careers in a resource-constrained country. METHODS: Qualitative semi-structured interviews were conducted with a purposive sample of 14 early-career and leading medical educators from all 9 medical schools and the 1 postgraduate institute in Sri Lanka. Thematic analysis was performed, informed by the three conceptual lenses of TPA: discursive-cultural, material-economic, and socio-political. RESULTS: Three themes were identified: faculty development as a career-building discourse (discursive-cultural); leadership focused on creating a workforce with expertise in medical education, equal to clinical medicine specialties (material-economic); and collaborative professional networks in health professions education originating from faculty development activities (socio-political). CONCLUSION: Using TPA, our findings highlight that faculty development can foster a powerful discourse for promoting academic careers in medical education. Medical education leaders can also play a critical role by establishing formal training programmes in medical education, and collaborative professional networks can improve visibility of careers in medical education, particularly when participants share expertise and resources between institutions and health professions, across the continuum of undergraduate to postgraduate training. TPA can also be used to better understand how cultural, material-economic and socio-political factors can enhance or hinder career development in different contexts, whether resource-limited or well-resourced.

Appraising the use of smartphones and apps when conducting qualitative medical education research: AMEE Guide No. 130.

Smartphone use is rampant in everyday life and is increasing in: patient management, teaching and learning of medicine and health research. There is untapped potential to use smartphones as research tools in MER for a range of research approaches. Qualitative research is increasingly common in medical education research (MER). Smartphone use as a research tool has not been well explored in MER and this Guide will be useful to researchers considering integrating smartphones specifically in qualitative MER. First, we discuss the potential for smartphones in qualitative MER. Then, we discuss the opportunities and drawbacks for using smartphones in qualitative MER. We then provide three principles to consider when conducting smartphone MER: communication, ethics and reflection. Next we share ten lessons that emerged from the literature and our experiences. We end by looking to the future of smartphones in qualitative MER and hope this Guide provides evidence-based information to optimise smartphone use in qualitative MER. This Guide is important as there is an urgent need to redefine ethical boundaries to account for blurred lines between personal and professional use of smartphones.

'Re-placing' professional practice.

While preparation for professional practice is conceived as placeless, it is enacted in place. Consequently, many professionals find themselves working in conditions significantly different than those they were educated in and for. This is especially relevant for new professionals arriving in rural settings after preparation in urban programs, where metrocentric models of orientation to practice are implicitly privileged. The consequent dis-join between practice and place often results in new professionals feeling 'out of place' and questioning their professional competence. It also results in settings outside the metrocentric norm being viewed as less desirable practice contexts. Negative desirability hinders professional recruitment, while feeling out of place and incompetent hinders professional retention; both are longstanding issues in rural communities. Recent developments in professional education and practice standards emphasise adaptability to practise in specific contexts. However, 'context,' a primary focus to date for rural preparation is presented as a largely static backdrop that needs to be accommodated to engage in the 'real practice' one was trained for. Drawing on the spatial turn in social theory, we argue that place both shapes and is shaped by professionals and their practices and as such, must be engaged with deeply and dynamically. This conceptualisation of the relationship between place and practice has critical implications for professional preparation. As interdisciplinary practitioners and researchers working in diverse contexts, we examine 'place' from a social constructivist perspective as a focal point for professional preparation.

"I Just Had No Idea What It Was Like to Be in Prison and What Might Be Helpful": Educator and Learner Views on Clinical Placements in Correctional Health.

Phenomenon: Correctional health services can provide quality learning experiences for medical students and graduate medical trainees, including through motivating learners to work with people involved with the justice system, and promoting understanding of the social determinants of health. Approach: We conducted 38 semi-structured interviews to examine the views of learners and educators on how to promote high quality clinical learning in correctional settings, with a focus on the Australian context. Participants included medical students; general practitioners who had undertaken graduate trainee placements; clinical staff involved in teaching and clinical supervision; and graduate program medical educators and university teachers from Australia, New Zealand, and Canada. Data were analyzed thematically. Findings: Clinical placements in correctional settings provided learning about the health of people involved in the justice system, but also beneficial clinical learning for working with a wide range of patients with complex health needs. Valued learnings included managing complex consultations, mental health and substance use disorders, and overcoming anxiety related to interacting with people in prison. Learner concerns included limited patient contact time, apprehension prior to placements, and stress related to experiences during the placements. This apprehension and stress could be mitigated by orientation and debriefing, and by appreciating healthcare professionals in correctional settings as advocates for their patients. Clinical supervision was perceived to be demanding in this context. Independent patient interaction was not usually possible for students and there could be short windows of time in which to provide direct patient care, making pauses for teaching difficult. Insights: Clinical placements in correctional health services provide experiential learning of direct relevance to medical student, and potentially to general practice trainee, curricula which is valuable even when learners do not have particular interest in correctional health. Furthermore, these placements may increase the capacity of the medical workforce to provide skilled care to other underserved populations. High quality learner and clinical supervisor experiences, and program scale and sustainability, require enhanced learning support systems through partnerships between correctional health services and education institutions. Required supports for learners include orientation to security arrangements, debriefing sessions which assist learners to distill their learning and to reflect on challenging experiences, and alternative learning opportunities for when direct patient consultations are not accessible. Supervisor teaching supports include shared teaching approaches in the correctional health clinics and added student support from university-based staff.

Differences between medical school and PGY1 learning outcomes: An explanation for new graduates not being "work ready"?

Background: Widespread concerns about new medical graduates' 'work readiness' may reflect, in part, differences in mandatory learning outcomes for medical students and new medical graduates.Purpose: To examine differences between required medical student and PGY1 (first year resident) training program outcomes, and the nature and magnitude of these differences.Method: Comparison, systematic identification and thematic analysis of differences between the graduate outcomes in the Australian Medical Council Standards for the Assessment and Accreditation of Primary Medical Programs and those in the New Zealand Curriculum Framework for Prevocational Training.Results: The relationship between these outcome statements were categorized as: essentially similar; continuity; partial discontinuity; and complete discontinuity of learning trajectory. Areas requiring substantial new learning may reflect medical schools' focus on individual student performance, and on learning and assessments based on single episodes of often uncomplicated illness. This contrasted with a post-graduate focus on integrated health care delivery by teams and management of complex illnesses over the whole patient care journey.Conclusions: Characterizing these marked differences between pre-graduate and postgraduate standards, within a trajectory of learning, explains some of the difficulties in students' preparation for work readiness. These could inform learning interventions to support new graduates' professional development to ensure patient safety. Development and revision of accreditation standards should include formal review against the expectations of the preceding and succeeding phases of learning.

Motivations of assessment item writers in medical programs: a qualitative study.

BACKGROUND: The challenge of generating sufficient quality items for medical student examinations is a common experience for medical program coordinators. Faculty development strategies are commonly used, but there is little research on the factors influencing medical educators to engage in item writing. To assist with designing evidence-based strategies to improve engagement, we conducted an interview study informed by self-determination theory (SDT) to understand educators' motivations to write items. METHODS: We conducted 11 semi-structured interviews with educators in an established medical program. Interviews were transcribed verbatim and underwent open coding and thematic analysis. RESULTS: Major themes included; responsibility for item writing and item writer motivations, barriers and enablers; perceptions of the level of content expertise required to write items; and differences in the writing process between clinicians and non-clinicians. CONCLUSIONS: Our findings suggest that flexible item writing training, strengthening of peer review processes and institutional improvements such as improved communication of expectations, allocation of time for item writing and pairing new writers with experienced writers for mentorship could enhance writer engagement.

Medical student perceptions of curricular influences on their wellbeing: a qualitative study.

BACKGROUND: Medical student mental health and wellbeing is highly topical and the subject of much research. While theoretically informed definitions of wellbeing abound, how do medical students themselves understand and perceive wellbeing? What aspects of the curriculum do they regard as affecting their wellbeing and mental health? This study explored these questions, and aimed to identify factors associated with student acceptability of wellbeing programs and interventions. METHODS: All students at an Australian undergraduate medical school (n = 619) were invited to complete a qualitative online questionnaire between 2017 and 2018 following the introduction of several wellbeing initiatives, including "Wellbeing Days" (WBD). WBD allow students to take single absence days for self-care. Open-ended questions were asked about perceptions and experience of mental health and wellbeing, and views on interventions to improve wellbeing such as WBD. Thematic analysis was conducted across all responses. Three authors developed preliminary themes, which were then refined and confirmed by all researchers. Thematic saturation was achieved within data from the 68 respondents, which included participants from all cohorts. RESULTS: Participants described wellbeing as positively experienced work/life balance, impacted by four factors; contact hours, peer relationships, staff relationships, and trust in how wellbeing initiatives were used. Long contact hours were deemed incompatible with self-care activities, maintaining employment, and seeking professional medical/psychological help. Peers could promote wellbeing by offering social and academic support, but also undermine wellbeing by being competitors. Degree of trust, engagement and communication with staff influenced acceptability of interventions. Participants viewed initiatives such as WBD favourably, but distrust of peers, and of staff, led to perceptions that WBD could be prone to misuse, or used for surveillance rather than support. CONCLUSION: Our findings suggest that wellbeing days which allow self-care, reduction in contact hours, and peer support may promote student wellbeing, but the acceptability of any interventions is influenced by relationships between staff and students, and in particular, trust in these relationships. We suggest strategies to strengthen trust and further research to investigate the relationship between trust and perceptions of wellbeing in self and peers.

Parental career expectations: effect on medical students' career attitudes over time.

BACKGROUND: Motivation to become a doctor has typically been conceived as arising from personal interests. However, it is not uncommon, particularly amongst those from collectivist cultures, for career choice to be motivated by a desire or need to fulfil parent expectations. Whether or not this motivation has longer term effects on the career satisfaction and performance of medical students is unknown. METHODS: Using three waves of survey data collection, applicants to medical school (n = 370) reported parent career expectations, parent career support and physician career values. Those who gained a student place (n = 90) reported attitudes to their career at the end of their first year of study. Burnout and intentions regarding practice location were assessed during the fifth and final year of study (n = 81). Examination marks in Years 1 and 5 assessed academic performance. RESULTS: Those with more highly educated parents reported more support, but parent support had no relationship with students' academic performance or attitudes to their career. Perceived parent career expectation was higher amongst younger applicants and those from a non-Western background. Expectations had a small positive correlation with applicants' valuing of prestige and a small negative correlation with valuing service. Medical students with high parent expectation at selection had, a year later, more negative attitudes to medicine as a career. Parent expectation had a significant indirect effect on Year-5 burnout. Higher parent expectation was related to lower Year-5 academic grades, but after Year-1 grades were accounted for, this relationship was no longer significant. CONCLUSIONS: Medical students who perceive that their parents expect them to choose a prestigious career in line with family or cultural values may be more ambivalent about their career choice once in medical school. They may also be more likely to experience longer term burnout but there was little evidence that they might have lower academic performance.