Lessons learned spanning 17 years of experience with three consecutive nationwide competency based medical education training plans.

Introduction: Curricula for postgraduate medical education have transformed since the introduction of competency based medical education (CBME). Postgraduate training plans offer broader training with different competencies and an outcome-based approach, in addition to the medical technical aspects of training. However, CBME also has its challenges. Over the past years, critical views have been shared on the potential drawbacks of CBME, such as assessment burden and conflicts with practicality in the workplace. Recent studies identified a need for a better understanding of how the evolving concept of CBME has been translated to curriculum design and implemented in the practice of postgraduate training. The aim of this study was to describe the development of CBME translations to curriculum design, based on three consecutive postgraduate training programs spanning 17 years. Method: We performed a document analysis of three consecutive Dutch gynecology and obstetrics training plans that were implemented in 2005, 2013, and 2021. We used template analysis to identify changes over time. Results: Over time, CBME-based curriculum design changed in several domains. Assessment changed from a model with a focus on summative decision to one with an emphasis on formative, low-stakes assessments aimed at supporting learning. The training plans evolved in parallel to evolving educational insights, e.g., by placing increasing emphasis on personal development. The curricula focused on a competency-based concept by introducing training modules and personalized authorization based on feedback rather than on a set duration of internships. There was increasing freedom in personalized training trajectories in the training plans, together with increasing trust towards the resident. Conclusion: The way CBME was translated into training plans has evolved in the course of 17 years of experience with CMBE-based education. The main areas of change were the structure of the training plans, which became increasingly open, the degree to which learning outcomes were mandatory or not, and the way these outcomes were assessed.

Conceptualizing Educational Comparability in Distributed Health Professions Education: A Scoping Review.

PURPOSE: This study aimed to create greater clarity about the current understanding and formulate a model of how educational comparability has been used in the literature to inform practice. METHOD: The authors conducted a literature search of 9 online databases, seeking articles published on comparability in distributed settings in health professions education before August 2021, with an updated search conducted in May 2023. Using a structured scoping review approach, 2 reviewers independently screened articles for eligibility with inclusion criteria and extracted key data. All authors participated in the descriptive analysis of the extracted data. RESULTS: Twenty-four articles published between 1987 and 2021 met the inclusion criteria. Most articles were focused on medical education programs (n = 21) and located in North America (n = 18). The main rationale for discussing comparability was accreditation. These articles did not offer definitions or discussions about what comparability means. The program logic model was used as an organizing framework to synthesize the literature on practices that schools undertake to facilitate and demonstrate comparability in the design (inputs), implementation (activities), and evaluation (outcomes) of distributed education. Inputs include common learning objectives, identical assessment tools and policies, governance models that enable clear communication, and reporting structure that is supported by technological infrastructure. Activities include faculty planning meetings and faculty development training. Outcomes include student experiences and academic performances. CONCLUSIONS: This study demonstrated that a more complex understanding of the dynamics of educational processes and practices is required to better guide the practice of educational comparability within distributed education programs. In addition to highlighting the need to develop an accepted definition of educational comparability, further elucidation of the underlying dynamics among input, activities, and outcomes would help to better determine what drivers should be prioritized when considering educational change with attention to context within distributed education.

'Yourself in all your forms': A grounded theory exploration of identity safety in medical students.

INTRODUCTION: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment. METHODS: This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations. RESULTS: Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment. DISCUSSION: Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

Postgraduate Selection in Medical Education: A Scoping Review of Current Priorities and Values.

PURPOSE: The process of screening and selecting trainees for postgraduate training has evolved significantly in recent years, yet remains a daunting task. Postgraduate training directors seek ways to feasibly and defensibly select candidates, which has resulted in an explosion of literature seeking to identify root causes for the problems observed in postgraduate selection and generate viable solutions. The authors therefore conducted a scoping review to analyze the problems and priorities presented within the postgraduate selection literature to explore practical implications and present a research agenda. METHOD: Between May 2021 and February 2022, the authors searched PubMed, EMBASE, Web of Science, ERIC, and Google Scholar for English language literature published after 2000. Articles that described postgraduate selection were eligible for inclusion. 2,273 articles were ultimately eligible for inclusion. Thematic analysis was performed on a subset of 100 articles examining priorities and problems within postgraduate selection. Articles were sampled to ensure broad thematic and geographical variation across the breadth of articles that were eligible for inclusion. RESULTS: Five distinct perspectives or value statements were identified in the thematic analysis: (1) Using available metrics to predict performance in postgraduate training; (2) identifying the best applicants via competitive comparison; (3) seeking alignment between applicant and program in the selection process; (4) ensuring diversity, mitigation of bias, and equity in the selection process; and (5) optimizing the logistics or mechanics of the selection process. CONCLUSIONS: This review provides insight into the framing and value statements authors use to describe postgraduate selection within the literature. The identified value statements provide a window into the assumptions and subsequent implications of viewing postgraduate selection through each of these lenses. Future research must consider the outcomes and consequences of the value statement chosen and the impact on current and future approaches to postgraduate selection.

What is the future of artificial intelligence in obstetrics? A qualitative study among healthcare professionals.

OBJECTIVE: This work explores the perceptions of obstetrical clinicians about artificial intelligence (AI) in order to bridge the gap in uptake of AI between research and medical practice. Identifying potential areas where AI can contribute to clinical practice, enables AI research to align with the needs of clinicians and ultimately patients. DESIGN: Qualitative interview study. SETTING: A national study conducted in the Netherlands between November 2022 and February 2023. PARTICIPANTS: Dutch clinicians working in obstetrics with varying relevant work experience, gender and age. ANALYSIS: Thematic analysis of qualitative interview transcripts. RESULTS: Thirteen gynaecologists were interviewed about hypothetical scenarios of an implemented AI model. Thematic analysis identified two major themes: perceived usefulness and trust. Usefulness involved AI extending human brain capacity in complex pattern recognition and information processing, reducing contextual influence and saving time. Trust required validation, explainability and successful personal experience. This result shows two paradoxes: first, AI is expected to provide added value by surpassing human capabilities, yet also a need to understand the parameters and their influence on predictions for trust and adoption was expressed. Second, participants recognised the value of incorporating numerous parameters into a model, but they also believed that certain contextual factors should only be considered by humans, as it would be undesirable for AI models to use that information. CONCLUSIONS: Obstetricians' opinions on the potential value of AI highlight the need for clinician-AI researcher collaboration. Trust can be built through conventional means like randomised controlled trials and guidelines. Holistic impact metrics, such as changes in workflow, not just clinical outcomes, should guide AI model development. Further research is needed for evaluating evolving AI systems beyond traditional validation methods.

Followership in interprofessional healthcare teams: a state-of-the-art narrative review.

OBJECTIVE: A state-of-the-art (SotA) literature review-a type of narrative review- was conducted to answer: What historical developments led to current conceptualisations of followership in interprofessional healthcare teams (IHTs)? DESIGN: Working from a constructivist orientation, SotA literature reviews generate a chronological overview of how knowledge evolved and presents this summary in three parts: (1) this is where we are now, (2) this is how we got here and (3) this is where we should go next. Using the SotA six-stage methodology, a total of 48 articles focused on followership in IHTs were used in this study. RESULTS: Articles about followership within IHTs first appeared in 1993. Until 2011, followership was framed as leader-centric; leaders used their position to influence followers to uphold their dictums. This perspective was challenged when scholars outside of healthcare emphasised the importance of team members for achieving goals, rejecting a myopic focus on physicians as leaders. Today, followership is an important focus of IHT research but two contradictory views are present: (1) followers are described as active team members in IHTs where shared leadership models prevail and (2) conceptually and practically, old ways of thinking about followership (ie, followers are passive team members) still occur. This incongruity has generated a variable set of qualities associated with good followership. CONCLUSIONS: Leadership and followership are closely linked concepts. For leaders and followers in today's IHTs to flourish, the focus must be on followers being active members of the team instead of passive members. Since theories are increasingly encouraging distributed leadership, shared leadership and/or situational leadership, then we must understand the followership work that all team members need to harness. We need to be cognizant of team dynamics that work within different contexts and use leadership and followership conceptualisations that are congruent with those contexts.

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.

Stakes of Assessments in Residency: Influence on Previous and Current Self-Regulated Learning and Co-Regulated Learning in Early Career Specialists.

Introduction: Assessments drive learning but the influence of the stakes of the assessments on self-regulated (SRL) during and after residency are unknown. As early career specialists (ECS) must continue learning independently, the answer to this is important as it may inform future assessments with the potential to promote life-long learning after graduation. Methods: We utilized constructivist grounded theory to explore the perspectives of eighteen ECS on the influence of stakes of assessments within residency on their SRL during training and in current practice. We conducted semi-structured interviews. Results: We initially set out to examine the influence of the stakes of assessments on SRL during residency and after graduation. However, it was apparent that learners increasingly engaged with others in co-regulated learning (CRL) as the perceived stakes of the assessments increased. The individual learner's SRL was embedded in CRL in preparation for the various assessments in residency. For low-stakes assessments, the learner engaged in less CRL, taking less cues from others. As stakes increased, the learner engaged in more CRL with peers with similar intellectual level and supervisors to prepare for these assessments. SRL and CRL influenced by assessments in residency had a knock-on effect in clinical practice as ECS in: 1) developing clinical reasoning, 2) improving doctor-patient communication and negotiation skills, and 3) self-reflections and seeking feedback to deal with expectations of self or others. Discussion: Our study supported that the stakes of assessments within residency reinforced SRL and CRL during residency with a continued effect on learning as ECS.

Academic half days, noon conferences and classroom-based education in postgraduate medical education: a scoping review.

BACKGROUND: Classroom-based education (CBE) is ubiquitous in postgraduate medical education (PGME), but to date no studies have synthesized the literature on the topic. We conducted a scoping review focusing on academic half days and noon conferences. METHODS: We searched 4 databases (MEDLINE [OVID], Embase [OVID], ERIC [EBSCO] and Web of Science) from inception to December 2021, performed reference and citation harvesting, and applied predetermined inclusion and exclusion criteria to our screening. We used 2 frameworks for the analysis: "experiences, trajectories and reifications" and "description, justification and clarification." RESULTS: We included 90 studies, of which 55 focused on resident experiences, 29 on trajectories and 6 on reification. We classified 44 studies as "description," 38 as "justification" and 8 as "clarification." In the description studies, 12 compared academic half days with noon conferences, 23 described specific teaching topics, and 9 focused on resources needed for CBE. Justification studies examined the effects of CBE on outcomes, such as examination scores (17) and use of teaching strategies in team-based learning, principles of adult learning and e-learning (15). Of the 8 clarification studies, topics included the role of CBE in PGME, stakeholder perspectives and transfer of knowledge between classroom and workplace. INTERPRETATION: Much of the existing literature is either a description of various aspects of CBE or justification of particular teaching strategies. Few studies exist on how and why CBE works; future studies should aim to clarify how CBE facilitates resident learning within the sociocultural framework of PGME.

Learning in Tension: A Case Study Examining What Internal Medicine Residents Learn in the Ambulatory Care Setting.

Introduction: Medical care of patients with complex conditions has shifted to the ambulatory setting, whereas current knowledge of resident learning is primarily based on studies from inpatient settings. Preparing trainees to adapt to this shift necessitates an understanding of what internal medicine (IM) residents currently learn during ambulatory rotations. The aim of this study is to identify what residents learn during their ambulatory care experience. Methods: Using a qualitative instrumental case study design, the authors conducted separate focus groups with IM trainees (n = 15), supervisors (n = 16), and program directors (n = 5) from two IM programs in New York City, USA in 2019. Participants were invited via email, and focus group sessions were complemented by document analysis of ambulatory syllabi. Results: Based on focus group commentary and document analysis, content learned in the ambulatory setting encompassed three domains; 1) patient needs, 2) the resident's role within a healthcare team, and 3) health system opportunities and limitations. Residents also learned about tensions within and between these domains including the skills needed to care for patients versus the skills acquired, a desire for ownership of patient care versus fragmented care, and time allotted versus time required. Discussion: This study revealed two outcomes about what residents learn during their ambulatory care experience. First, learning content largely fell into three domains. Second, residents learned about the tensions between ideal care delivery and the realities of practice. These results highlight the imperative to better align curricula with clinical environments to meet the learning needs of residents.

Shame at the Gates of Medicine: A Hermeneutic Exploration of Premedical Students' Experiences of Shame.

PURPOSE: Little is known about the nature of shame in students attempting to enter medical school, despite its potential to impact well-being and professional identity formation during training. In this study, the authors used hermeneutic phenomenology to ask: How do premedical students experience shame as they apply to medical school? METHOD: From September 2020 to March 2021, the authors recruited 12 students from a U.S. Master of Biomedical Sciences program who intended to apply to medical school. Data collection consisted of each participant creating a "rich picture" depicting a shame experience during their premedical training, a semistructured interview that deeply explored this and other shame experiences, and a debriefing session. Data were analyzed using Ajjawi and Higgs's 6 steps of hermeneutic analysis. RESULTS: Self-concept, composed of an individual's identities and contingencies of self-esteem, was central to participants' shame experiences. Through a confluence of past and future self-concepts and under the influence of external factors and the weight of expectations, shame often destabilized participants' present self-concepts. This destabilization occurred because of events related to application processes (repeat Medical College Admission Test attempts), interpersonal interactions (prehealth advisor meetings), and objective performance measures (grades, test scores). Participants' efforts to restabilize their self-concept catalyzed specific identity processes and self-concept formation. CONCLUSIONS: Shame provided a window into the emotional experiences, identity processes, and ideologies that shape students' attempts to enter medical school. The authors discuss the central role of contingencies of self-esteem, the potential origins of performance-based self-esteem in trainees, and the identity negotiation and identity work involved in shame reactions. They call for the adoption of contingencies of self-esteem within current conceptualizations of professional identity formation; training for faculty and prehealth advisors about the nature of shame in premedical learners; and consideration of the consequential validity of standardized tests, which may trigger damaging shame.

Training infectious diseases senior residents during COVID-19: The impact and the lessons learnt.

BACKGROUND: The COVID-19 pandemic had major impact on the training of Infectious Diseases (ID) residents across the globe. They were part of the frontline staff, while at the same time training to be ID physicians. This study focused on identifying their capability, i.e. the ability to adapt existing competencies to new situations, which is now recognised as an essential element of professional practice. AIM: This study explored what ID residents learnt and how they learnt as they adapted to working in this unpredictable and challenging COVID-19 pandemic. METHODS: This qualitative explorative study was based in the Infectious Diseases Senior Residency Programme across three training institutions in Singapore. Individual semi-structured interviews were conducted. Data were analysed using a template analysis technique. RESULTS: Nine ID residents participated in this study. They learnt to engage with uncertainty in a meaningful way by relying on prior training and rapidly learning how to most effectively learn (metacognition). Learning was enhanced by collaboration between multidisciplinary health professionals, strong leadership and intrinsic motivation from personal interest in ID. They learnt through observing how senior faculty approached and managed the COVID-19 situation. CONCLUSION: When learning for future capability in a rapidly evolving situation, role-modelling and mentoring are essential as available information resources may still not provide the learning from skilled doctors with actual experiences managing complex, uncertain situations.

Cardiovascular mortality in women in their forties after hypertensive disorders of pregnancy in the Netherlands: a national cohort study.

BACKGROUND: Hypertensive disorders of pregnancy are associated with cardiovascular disease later in life. Given that hypertensive disorders of pregnancy often occur at a relatively young age, there might be an opportunity to use preventive measures to reduce the risk of early cardiovascular disease and mortality. The aim of this study was to assess the risk of cardiovascular mortality in women after a hypertensive disorder of pregnancy. METHODS: In this population-based cohort study, the Netherlands Perinatal Registry (PRN) and the national death registry at the Dutch Central Bureau for Statistics were linked. We analysed women in the Netherlands with a first birth during 1995-2015 to determine the association between cardiovascular mortality and hypertensive disorders of pregnancy (based on recorded diastolic blood pressure or proteinuria, or both). We analysed the association between the highest diastolic blood pressure measured in pregnancy and cardiovascular mortality and constructed survival curves to assess cardiovascular mortality after hypertensive disorders of pregnancy, specifically pre-eclampsia and gestational hypertension. To differentiate between the severity of hypertensive disorders of pregnancy, cardiovascular mortality was assessed in women with a combination of hypertensive disorders of pregnancy with preterm birth (gestational age <37 weeks) and growth restriction (birthweight in the 10th percentile or less). All hazard ratios (HRs)were adjusted for maternal age. FINDINGS: Between Jan 1, 1995, and Dec 31, 2015, the PRN contained 2 462 931 deliveries and 1 625 246 women. In 1 243 890 women data on their first pregnancy were available and were included in this analysis after linkage, with a median follow-up time of 11·2 years (IQR 6·1-16·3). 259 177 (20·8%) women had hypertensive disorders of pregnancy, and of these 45 482 (3·7%) women had pre-eclampsia and 213 695 (17·2%) women had gestational hypertension; 984 713 (79·2%) women did not develop hypertension in their first pregnancy. Compared with women without hypertensive disorders of pregnancy, the risk of death from any cause was higher in women who had hypertensive disorders (HR 1·30 [95% CI 1·23-1·37], p<0·001), pre-eclampsia (1·65 [1·48-1·83]; p<0·0001), and gestational hypertension (1·23 [1·16-1·30]; p<0·0001). Those women with pre-eclampsia had a higher risk of cardiovascular mortality compared with those without any hypertensive disorders of pregnancy (adjusted HR 3·39 [95% CI 2·67-4·29]), as did those with gestational hypertension (2·22 [1·91-2·57]). For women with a history of hypertensive disorders of pregnancy combined with preterm birth (gestational age <37 weeks) and birthweight in the 10th percentile or less, the adjusted HR for cardiovascular mortality was 6·43 (95% CI 4·36-9·47), compared with women without a hypertensive disorder of pregnancy. The highest diastolic blood pressure measured during pregnancy was the strongest risk factor for cardiovascular mortality (for 80-89 mm Hg: adjusted HR 1·47 [95% CI 1·00-2·17]; for 130 mm Hg and higher: 14·70 [7·31-29·52]). INTERPRETATION: Women with a history of hypertensive disorders of pregnancy have a risk of cardiovascular mortality that is 2-3 times higher than that of women with normal blood pressure during pregnancy. The highest measured diastolic blood pressure during pregnancy is an important predictor for cardiovascular mortality later in life; therefore, women who have hypertensive disorders of pregnancy should be given personalised cardiovascular follow-up plans to reduce their risk of cardiovascular mortality. FUNDING: None.

Trainees' perceptions of being allowed to fail in clinical training: A sense-making model.

INTRODUCTION: Clinical supervisors allow trainees to fail during clinical situations when trainee learning outweighs concerns for patient safety. Trainees perceive failure as both educationally valuable and emotionally draining; however, the nuance of supervised failures has not been researched from the trainee perspective. This study explored trainees' awareness and their experience of failure and allowed failure to understand those events in-depth. METHODS: We interviewed 15 postgraduate trainees from nine teaching sites in Europe and Canada. Participants were a purposive sample, representing 1-10 years of clinical training in various specialties. Consistent with constructivist grounded theory, data collection and analysis were iterative, supporting theoretical sampling to explore themes. RESULTS: Trainees reported that failure was a common, valuable, and emotional experience. They perceived that supervisors allowed failure, but they reported never having it explicitly confirmed or discussed. Therefore, trainees tried to make sense of these events on their own. If they interpreted a failure as allowed by the supervisor, trainees sought to ascertain supervisory intentions. They described situations where they judged supervisor's intentions to be constructive or destructive. DISCUSSION: Our results confirm that trainees perceive their failures as valuable learning opportunities. In the absence of explicit conversations with supervisors, trainees tried to make sense of failures themselves. When trainees judge that they have been allowed to fail, their interpretation of the event is coloured by their attribution of supervisor intentions. Perceived intentions might impact the educational benefit of the experience. In order to support trainees' sense-making, we suggest that supervisory conversations during and after failure events should use more explicit language to discuss failures and explain supervisory intentions.

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.

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.

A phenomenology of direct observation in residency: Is Miller's 'does' level observable?

INTRODUCTION: Guidelines on direct observation (DO) present DO as an assessment of Miller's 'does' level, that is, the learner's ability to function independently in clinical situations. The literature, however, indicates that residents may behave 'inauthentically' when observed. To minimise this 'observer effect', learners are encouraged to 'do what they would normally do' so that they can receive feedback on their actual work behaviour. Recent phenomenological research on patients' experiences with DO challenges this approach; patients needed-and caused-some participation of the observing supervisor. Although guidelines advise supervisors to minimise their presence, we are poorly informed on how some deliberate supervisor participation affects residents' experience in DO situations. Therefore, we investigated what residents essentially experienced in DO situations. METHODS: We performed an interpretive phenomenological interview study, including six general practice (GP) residents. We collected and analysed our data, using the four phenomenological lenses of lived body, lived space, lived time and lived relationship. We grouped our open codes by interpreting what they revealed about common structures of residents' pre-reflective experiences. RESULTS: Residents experienced the observing supervisor not just as an observer or assessor. They also experienced them as both a senior colleague and as the patient's familiar GP, which led to many additional interactions. When residents tried to act as if the supervisor was not there, they could feel insecure and handicapped because the supervisor was there, changing the situation. DISCUSSION: Our results indicate that the 'observer effect' is much more material than was previously understood. Consequently, observing residents' 'authentic' behaviour at Miller's 'does' level, as if the supervisor was not there, seems impossible and a misleading concept: misleading, because it may frustrate residents and cause supervisors to neglect patients' and residents' needs in DO situations. We suggest that one-way DO is better replaced by bi-directional DO in working-and-learning-together sessions.

Overextending: A Qualitative Study of Trainees Learning at the Edge of Evolving Expertise.

Background: The challenge of graduate medical education is to prepare physicians for unsupervised practice while ensuring patient safety. Current approaches may inadequately prepare physicians due to limited opportunities for autonomy. Recent work on how trainees gain autonomy shows that they actively influence their supervisors' entrustment decisions. If program directors more clearly understand how trainees experience increasing independence, they may better sensitize trainees to the deliberations they will face during patient care. Objective: The authors sought to explore how trainees experience lessening supervision as their clinical training advances. Methods: Using constructivist grounded theory, the authors recruited trainees from various specialties and training levels via email and conducted 17 semi-structured interviews from 2019 to 2020 to solicit clinical experiences during which their perceived autonomy changed. Through constant comparison and iterative analysis, key themes and conceptual relationships were identified. Results: Seventeen trainees from 4 specialties described novel clinical situations that required "overextending," or going beyond their perceived edge of evolving expertise. This move represented a spectrum based on perceived locus of control, from deliberate overextending driven by trainees, to forced overextending driven by external factors. Trainee judgments about whether or not to overextend were distilled into key questions: (1) Can I do it? (2) Must I do it? (3) Do I want to do it? and (4) Is it safe to do it? More advanced trainees posed a fifth question: (5) Am I missing something? Conclusions: Decisions to move into the realm of uncertainty about capabilities carried weight for trainees. In making deliberative judgments about overextending, they attempted to balance training needs, capability, urgency, and patient safety.

Medical Students' Socialization Tactics When Entering a New Clinical Clerkship: A Mixed Methods Study of Proactivity.

PURPOSE: Socialization into clinical clerkships is difficult in part due to ambiguity around students' new roles and expected behaviors. Being proactive reduces ambiguity and is essential to socialization. Proactive behavior can be taught and goes beyond having a proactive personality. Among students entering new undergraduate clinical clerkships, this study aimed to investigate (1) reported proactive behaviors and their association with social integration and (2) enabling and inhibiting factors for proactive behavior. METHOD: This study was conducted at the 5-year MBBS program at Western Sydney University during academic year 2019-2020. Using a convergent mixed methods approach, survey and interview data from third-, fourth-, and fifth-year students were collected. Surveys explored 5 proactive behaviors: feedback seeking, information seeking, task negotiation, positive framing, and relationship building. Interviews elicited descriptions of how students described their proactivity and what influenced students to be proactive when entering a new clerkship. Data were integrated using the following the thread and mixed methods matrix techniques. RESULTS: Students exhibited all 5 proactive behaviors. Survey data showed positive framing and task negotiation had the highest and lowest scores, respectively. Only positive framing correlated significantly with social integration scores (r = 0.27; P < .01), but this contrasted to interviews, in which students described how other proactive behaviors also led to social integration. Proactive behavior scores decreased across academic years. Integrated data showed 3 linked antecedents to whether students exhibited proactive behavior: feeling capable of being proactive, individual intention to be proactive, and the immediate environment and system-level factors. CONCLUSIONS: Students who framed the experience positively were more likely to report increased social integration. Initiating task negotiation was challenging for most students. The authors propose a conceptual model for proactivity and social integration to support socialization and learning during clinical transitions for future research and interventional design.