Thresholds of becoming: an exploration of threshold concepts as a means to support professional identity formation in competency-based curricula.

Inherent in every clinical preceptor's role is the ability to understand the learning needs of individual trainees, enabling them to meet their potential. Competency-based medical education frameworks have been developed to this end, but efforts to identify behaviours and activities that define competence are based on mapping knowledge, skills and ability, which can be difficult to integrate into a comprehensive picture of who the trainee is becoming. Professional identity formation, in contrast, prioritizes attention to who trainees are becoming, but provision of detailed guidance to preceptors on how to best support this form of development is challenging. The tension that results limits our ability to optimally support learners as strengths in competency development may mask professional identity development gaps and vice versa. To address this tension, this paper examines how the theory of threshold concepts - troublesome ideas that, once appreciated, fundamentally change how you understand and approach a particular activity - can shine light on professional identity formation and its relationship with developing competence. The recognition and identification of threshold concepts is offered as a means to improve our ability to identify, discuss and support behaviours and actions that impact the learner's capacity to act competently as they develop their identity at various stages of training.

Before the scalpel: Exploring surgical residents' preoperative preparatory strategies.

OBJECTIVE: This study sought to increase understanding of preoperative preparatory strategies utilised by senior surgical residents and identify how social and material forces come together to shape practice. SUMMARY/BACKGROUND DATA: Preoperative preparation can play a powerful role in operative learning. Residents rarely receive guidance, feedback, or explicit expectations on how to prepare for the OR. Understanding current practice and how to support preoperative preparation represents an important gap in our efforts to improve surgical training. METHODS: Constructivist grounded theory with sensitizing concepts from sociomateriality guided data collection and analysis. Fifteen senior surgical residents from a range of surgical disciplines were purposefully sampled and participated in an in-depth individual interview. Two return-of-finding focus groups followed with seven residents. Rigor was enhanced through constant comparison, theoretical sampling, pursuit of discrepant data, and investigator triangulation. RESULTS: Residents utilised a range of strategies addressing four areas of focus: develop technical skills, improve procedural knowledge, enhance patient-specificity, and know surgical preferences. However, residents also described receiving limited guidance on what it means to 'be prepared' and experience significant challenges in achieving preparedness. A mix of social and material things that enabled or constrained preparatory efforts influenced individual strategies. These included rotation structure, relationships, the OR list, and time. CONCLUSIONS: Our findings offer possible solutions by elaborating on preparatory variability and considerations for residents, faculty, and programs to improve practice. As a first step, we suggest programs begin to engage in explicit dialogue and reflection with their residents, faculty, and residency program committees.

Relying on others' reliability: challenges in clinical teaching assessment.

BACKGROUND: The quality of the data generated from internally created faculty teaching instruments often draws skepticism. Strategies aimed at improving the reliability and validity of faculty teaching assessments tend to revolve around literature searches for a replacement instrument(s). PURPOSE: The purpose was to test this "search-and-apply" method and discuss our experiences with it within the context of observational assessment practice. METHOD: In a naturalistic pilot test, two previously validated faculty assessment instruments were paired with a global question. The reliability of both metrics was estimated. RESULTS: Generalizability analyses indicated that for both pilot tested faculty teaching instruments, the global question was a more reliable measure of perceived clinical teaching effectiveness than a multiple-item inventory. Item analysis with Cronbach's coefficient alpha suggested redundant instrument content. Rater error accounted for the greatest proportion of the variance and straight-line responses occurred in approximately 28% of residents' appraisals. CONCLUSIONS: The results of the present study draw attention to one of the common fallacies surrounding instrument-based assessment in medical education; the solution to improving one's assessment practice primarily involves identifying a previously published instrument from the literature. Academic centers need to invest in ongoing quality control efforts including the pilot testing of any proposed instruments.

An exploration of faculty perspectives on the in-training evaluation of residents.

PURPOSE: The in-training evaluation report (ITER) is the most widely used approach to the evaluation of residents' clinical performance. Participants' attitudes toward the process may influence how they approach the task of resident evaluation. Whereas residents find ITERs most valuable when they perceive their supervisors to be engaged in the process, faculty attitudes have not yet been explored. The authors studied faculty supervisors' experiences and perceptions of the ITER process to gain insight into the factors that influence faculty engagement. METHOD: Using a grounded theory approach, semistructured interviews were completed in 2008 with a purposive sample of 17 faculty involved in resident evaluation at one Canadian medical school. Constant comparative analysis for emergent themes was conducted. RESULTS: Three major themes emerged: (1) Faculty engagement was apparent, with a widely held view that ITERs were a worthwhile endeavor. (2) Fragmentation of the evaluation system compromised evaluators' ability to produce meaningful ITERs. Fragmentation appeared to be a system problem, elements of which included time constraints, inconsistency in approach to ITE, and lack of continuity between educational assignments. (3) Faculty found the challenge of giving negative feedback daunting and struggled to avoid harming residents. CONCLUSIONS: Faculty engagement in the ITER process may be compromised by both system and interpersonal challenges. These challenges may render ITERs less meaningful than faculty intend. Training programs must complement ITE with other tools to achieve robust systems of evaluation.

A randomized trial of pictorial versus prose-based medication information pamphlets.

OBJECTIVE: The goal of this study was to compare prose and pictorial-based information pamphlets about the medication methotrexate in the domains of free recall, cued recall, comprehension and utility. METHODS: A single blind, randomized trial of picture versus prose-based information pamphlets including 100 participants aged 18-65 years of age, who had not completed high school, could read English, and had no prior knowledge about methotrexate. Superiority of pamphlet type was assessed using immediate free recall, cued recall and comprehension. RESULTS: There were no differences between picture and prose pamphlets in free recall, cued recall, and comprehension either immediately or after a 1-week interval. Immediate free recall of important information was 17-26%; free recall fell even lower to 7-16% after 1 week. The pictorial pamphlet was preferred over the prose-based pamphlet. CONCLUSION: This study found no benefit in free recall, cued recall, or comprehension through the addition of pictograms to a simple prose-based medication pamphlet. PRACTICE IMPLICATIONS: In order for them to be effective in clinical practice, even simple medication information pamphlets that have been assessed for patients' ability to comprehend them cannot be used as the sole means for conveying important medication-related information to patients.

The sum of the parts detracts from the intended whole: competencies and in-training assessments.

OBJECTIVES: Despite the fact that Canadian residency programmes are required to assess trainees' performance within the context of the CanMEDS Roles Framework, there has been no inquiry into the potential relationship between residents' perceptions of the framework and their in-training assessments (ITA). Using data collected during the study of ITA, we explored residents' perceptions of these competencies. METHODS: From May 2006-07, a purposive sample of 20 resident doctors from internal medicine, paediatrics, and surgery were interviewed about their ITA experiences. Data collection and analysis proceeded in an iterative fashion consistent with grounded theory. In April 2008, a summary of recurrent themes was presented during a focus group interview of another five residents to afford further elaboration and refinement of thematic findings. RESULTS: The in-training assessment report (ITAR) was perceived as a primary source of residents' information on CanMEDS. Residents' familiarity with the set of competencies appeared to be quite limited and they possessed narrow definitions of the roles. Several trainees questioned the framework's relevance and some appeared confused about the overlapping nature of the roles. Although residents viewed the central Medical Expert role as the most relevant and important competency, they incorrectly perceived it as only involving the acquisition of medical and scientific knowledge. A visual rhetorical analysis of a typical ITAR suggests that the visual features found within this assessment tool may be misrepresenting the framework and the centrality of the Medical Expert role. CONCLUSIONS: Resident doctors' knowledge of CanMEDS was found to be limited. The visual structure of the ITAR appears to be a factor in residents' apparent distortion of the CanMEDS construct from its original holistic philosophy.

Rules of engagement: residents' perceptions of the in-training evaluation process.

BACKGROUND: In-training evaluation reports (ITERs) often fall short of their goals of promoting resident learning and development. Efforts to address this problem through faculty development and assessment-instrument modification have been disappointing. The authors explored residents' experiences and perceptions of the ITER process to gain insight into why the process succeeds or fails. METHOD: Using a grounded theory approach, semistructured interviews were conducted with 20 residents. Constant comparative analysis for emergent themes was conducted. RESULTS: All residents identified aspects of "engagement" in the ITER process as the dominant influence on the success of ITERs. Both external (evaluator-driven, such as evaluator credibility) and internal (resident-driven, such as self-assessment) influences on engagement were elaborated. When engagement was lacking, residents viewed the ITER process as inauthentic. CONCLUSIONS: Engagement is a critical factor to consider when seeking to improve ITER use. Our articulation of external and internal influences on engagement provides a starting point for targeted interventions.

'I don't have time': issues of fragmentation, prioritisation and motivation for education scholarship among medical faculty.

OBJECTIVES: Although lack of time has been frequently cited as a barrier to scholarship, there has been little inquiry into what specific factors medical faculty staff perceive as contributing to this dilemma. The purpose of the present study was to explore, in greater detail, lack of time as a barrier for faculty interested in pursuing education scholarship. METHODS: In 2004, as part of a cross-sectional, mixed-methods needs assessment, 73 (67.6%) medical faculty completed a questionnaire probing areas related to education scholarship. Additionally, one year later, 16 respondents (60% of those invited) each participated in one of three focus groups. RESULTS: Despite their interest and regardless of their background training in education, faculty were able, on average, to devote only negligible amounts of time to education scholarship. The most commonly reported barrier to these pursuits was lack of protected time. Further analysis revealed that the time-related factor appeared to involve three themes: fragmentation (where opportunities to work on education projects are sporadic); prioritisation (where work responsibilities including after-hours work and administrative workload complete for time, and where there is difficulty in securing financially remunerated time), and motivation (where the degree of recognition and support for education work by both the department and colleagues is limited). CONCLUSIONS: With respect to education scholarship, the dilemma caused by lack of time involves a complex, multi-faceted set of issues which extends beyond the number of hours available in a day. Personal interest and having background training in education do not appear to be sufficient to encourage involvement. Multiple institutional support mechanisms are necessary.

Measuring resident well-being: impostorism and burnout syndrome in residency.

BACKGROUND: Assessing resident well-being is becoming increasingly important from a programmatic standpoint. Two measures that have been used to assess this are the Clance Impostor Scale (CIS) and the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). However, little is known about the relationship between the two phenomena. OBJECTIVES: To explore the prevalence and association between impostorism and burnout syndrome in a sample of internal medicine residents. DESIGN: Anonymous, cross-sectional postal survey. PARTICIPANTS: Forty-eight internal medicine residents (postgraduate year [PGY] 1-3) at the Schulich School of Medicine & Dentistry (62.3% response rate). MEASUREMENTS AND MAIN RESULTS: Short demographic questionnaire, CIS and MBI-HSS. Impostorism and burnout syndrome were identified in 43.8% and 12.5% of residents, respectively. With the exception of a negative correlation between CIS scores and the MBI's personal accomplishment subscale (r = -.30; 95% CI -.54 to -.02), no other significant relations were identified. Foreign-trained residents were more likely to score as impostors (odds ratio [OR] 10.7; 95% CI 1.2 to 98.2) while senior residents were more likely to experience burnout syndrome (OR 16.5 95% CI 1.6 to 168.5). CONCLUSIONS: Both impostorism and burnout syndrome appear to be threats to resident well-being in our program. The lack of relationship between the two would suggest that programs and researchers wishing to address the issue of resident distress should consider using both measures. The finding that foreign-trained residents appear to be more susceptible to impostorism warrants further study.

Education scholarship: it's not just a question of 'degree'.

BACKGROUND: Although medical faculty are frequently encouraged to participate in education scholarship, there is a paucity of literature addressing how to support those who wish to do so. AIMS: The purpose of this study was to explore faculty involvement in and support needs for pursuing education scholarship. METHODS: A purposive sample of 108 medical faculty with an interest in medical education were invited to participate in a two-phase, mixed-methods study (survey and focus groups). RESULTS: Seventy-three faculty (67.6%) completed the questionnaire with 16 subsequently participating in focus group sessions. Nearly 40% had enrolled in or completed formal education training. Although the majority had been involved in at least one education project during the past five years, few had received funding or published their work. Three support-related themes emerged: education research support; enhancing colleague interactions; and ongoing development activities. Three related barriers were identified: time, access to support staff, and knowledge of research methodology. No significant differences were identified between those with and without additional education training. CONCLUSIONS: Assisting faculty to participate in education scholarship is a complicated endeavor. Institutional supports should not be limited to those with advanced degrees nor rely on Master-level degree programs to provide all the necessary training.