Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review.

OBJECTIVE: We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented. DESIGN: We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance. DATA SOURCES: We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022. ELIGIBILITY CRITERIA: We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs' training was described. DATA EXTRACTION AND SYNTHESIS: The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency. RESULTS: Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes. CONCLUSION: This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations. PROSPERO REGISTRATION NUMBER: CRD42022369208.

Understanding how and why upskilling programmes for unregulated care providers can support health equity in underserved communities: a realist review protocol.

INTRODUCTION: Foot ulcers are one of the most devastating complications of diabetes mellitus leading to leg amputations. In Canada, systematically marginalised and racialised populations are more prone to developing foot ulcers and at higher risk of limb amputations. Shortages of regulated healthcare have hindered efforts to provide foot care. Upskilling unregulated care providers (UCPs) to deliver foot screening seems a reasonable solution to reduce limb loss. UCPs can advocate for health equity and deliver appropriate care. There is a need, however, to understand how and why an educational intervention for UCPs providing foot screening for these high-risk groups may or may not work. METHODS AND ANALYSIS: This realist review will follow the Realist And Meta-narrative Evidence Syntheses: Evolving Standards standards. First, we will develop an initial programme theory (PrT) based on exploratory searches and discussions with experts and stakeholders. Then, we will search MEDLINE, Embase, PsycINFO, ERIC, CINAHL and Scopus databases along with relevant sources of grey literature. The retrieved articles will be screened for studies focusing on planned educational interventions for UCPs related to diabetic foot assessment. Data regarding contexts, mechanisms and outcomes will be extracted and analysed using a realist analysis through an iterative process that includes data reviewing and consultation with our team. Finally, we will use these results to modify the initial PrT. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. The main output of this research will be an evidence-based PrT for upskilling programmes for UCPs. We will share our final PrT using text, tables and infographics to summarise our results and draw insights across papers/reports. For academic, clinical, social care and educational audiences, we will produce peer-reviewed journal articles, including those detailing the process and findings of the realist review and establishing our suggestions for effective upskilling programmes. PROSPERO REGISTRATION NUMBER: CRD42022369208.

The imperative for (and opportunities of) research on adaptive expertise in health professions education.

In this editorial, three Advances in Health Sciences Education editors argue for the importance and impact of adaptive expertise on the future of health professions education and work. They present a sample of the broad range of theory-informed research currently contributing to understanding and applying adaptive expertise in health professions education. They reflect on the unique opportunities that interdisciplinarity offers this endeavour. Finally they offer potential ways forward for continued efforts to advance collective understanding of education, expert development and health professions practice.

Toward 'seeing' critically: a Bayesian analysis of the impacts of a critical pedagogy.

Critical reflection supports enactment of the social roles of care, like collaboration and advocacy. We require evidence that links critical teaching approaches to future critically reflective practice. We thus asked: does a theory-informed approach to teaching critical reflection influence what learners talk about (i.e. topics of discussion) and how they talk (i.e. whether they talk in critically reflective ways) during subsequent learning experiences? Pre-clinical students (n = 75) were randomized into control and intervention conditions (8 groups each, of up to 5 interprofessional students). Participants completed an online Social Determinants of Health (SDoH) module, followed by either: a SDoH discussion (control) or critically reflective dialogue (intervention). Participants then experienced a common learning session (homecare curriculum and debrief) as outcome assessment, and another similar session one-week later. Blinded coders coded transcripts for what (topics) was said and how (critically reflective or not). We constructed Bayesian regression models for the probability of meaning units (unique utterances) being coded as particular what codes and as critically reflective or not (how). Groups exposed to the intervention were more likely, in a subsequent learning experience, to talk in a critically reflective manner (how) (0.096 [0.04, 0.15]) about similar content (no meaningful differences in what was said). This difference waned at one-week follow up. We showed experimentally that a particular critical pedagogical approach can make learners' subsequent talk, ways of seeing, more critically reflective even when talking about similar topics. This study offers the field important new options for studying historically challenging-to-evaluate impacts and supports theoretical assertions about the potential of critical pedagogies.

Making Concepts Material: A Randomized Trial Exploring Simulation as a Medium to Enhance Cognitive Integration and Transfer of Learning.

BACKGROUND: Simulation affords opportunities to represent functional relationships between conceptual (eg, anatomy) and procedural knowledge (eg, needle insertion technique) in ways that make them accessible to our many senses. Despite deprioritizing realism, such simulations may encourage trainees to create cognitive connections between these knowledge (ie, cognitive integration), which may improve transfer of learning. However, the impact of such "integrated instruction" has not been examined in simulation-based training. We developed integrated video- and simulator-based instructional modules for lumbar puncture training and compared their impacts on participants' retention, transfer, and conceptual knowledge. METHODS: During 1 hour of simulation-based training, we randomized 66 medical students to receive either (a) video-based procedural-only instruction, (b) integrated video-based instruction, or (c) integrated simulator-based instruction. One week later, we tested participants' retention and transfer performances and their conceptual knowledge on a written test. RESULTS: Simple mediation analyses revealed that compared with participants receiving procedural-only instruction, participants receiving integrated instruction had superior retention and transfer outcomes, mediated by gains in conceptual knowledge (all P < 0.01). We found no significant differences between the integrated groups for retention, transfer, or conceptual knowledge (all P > 0.01). CONCLUSIONS: We extended previous findings, showing integrated instruction (video- or simulator-based) improved trainees' conceptual knowledge, which mediated their improved retention and transfer. As an innovation, we demonstrated how simulators can facilitate cognitive integration by making abstract conceptual-procedural relationships material. In suggesting how researchers might capitalize further on simulator-based integration, we offer an alternative framework for designing simulations that emphasizes cognitive processes rather than simulator fidelity.

The Basic Science of Patient-Physician Communication: A Critical Scoping Review.

PURPOSE: Strong verbal communication skills are essential for physicians. Despite a wealth of medical education research exploring communication skills training, learners struggle to become strong communicators. Integrating basic science into the curriculum provides students with conceptual knowledge that improves learning outcomes and facilitates the development of adaptive expertise, but the conceptual knowledge, or "basic science," of patient-provider communication is currently unknown. This review sought to address that gap and identify conceptual knowledge that would support improved communication skills training for medical trainees. METHOD: Combining the search methodology of Arksey and O'Malley with a critical analytical lens, the authors conducted a critical scoping review of literature in linguistics, cognitive psychology, and communications to determine: what is known about verbal communication at the level of word choice in physician-patient interactions? Studies were independently screened by 3 researchers during 2 rounds of review. Data extraction focused on theoretical contributions associated with language use and variation. Analysis linked patterns of language use to broader theoretical constructs across disciplines. RESULTS: The initial search returned 15,851 unique studies, and 271 studies were included in the review. The dominant conceptual groupings reflected in the results were: (1) clear and explicit language, (2) patient participation and activation, (3) negotiating epistemic knowledge, (4) affiliative language and emotional bonds, (5) role and identity, and (6) managing transactional and relational goals. CONCLUSIONS: This in-depth exploration supports and contextualizes theory-driven research of physician-patient communication. The findings may be used to support future communications research in this field and educational innovations based on a solid theoretical foundation.

Case Report: Defining Applicant Attributes to Be Prioritized in the Selection of Child and Adolescent Psychiatry Subspecialty Residents at the University of Toronto.

Background/Objectives: The child and adolescent psychiatry (CAP) subspecialty training program at the University of Toronto was among the first fully accredited CAP programs in Canada. As one of Canada's largest CAP subspecialty programs, we attract many excellent applicants annually. While objectivity and transparency in the selection of candidates have been valued, it was unclear which applicant attributes should be prioritized. This quality improvement project was undertaken to identify the key applicant attributes that should be prioritized for admission to the program. Materials/Methods: An initial list of attributes was compiled by project team members and feedback solicited. Through iterative design, this list was categorized into "end products," "branding attributes" and "generic attributes." The "end products" were removed as these represented outputs of training rather than attributes on which applicant selection should be based. Subsequent steps involved only the "branding" and "generic" attributes. A consensus-building exercise led to the creation of two short-lists of five attributes within each category. Finally, a paired-comparison forced choice methodology was used to determine the ranking of these attributes in order of importance when assessing applicants. Results: The final lists of "generic" and "branding" attributes developed through a consensus-building exercise are presented in rank order based on the paired-comparison methodology. The overall response rate for the forced choice electronic survey was 49% of faculty and learners. Conclusions/Discussion: This project used an iterative process of consensus building & pairwise comparison to prioritize key attributes for assessing trainee selection to the program. Going forward, these attributes will be incorporated into the file review and interview portions of our admissions process. In addition to emphasizing these priority attributes in admissions, there are implications for other aspects of the program including curriculum and faculty development, as well as guiding the overall mission and vision for the Division. A similar process could be undertaken by other training programs seeking to identify priority attributes for admission to their programs.

Assessing undergraduate medical education through a generalist lens.

PROBLEM BEING ADDRESSED: Medical schools aim to integrate the values of generalism into their undergraduate programs. However, currently no program has been described to measure the degree to which formal curricular materials represent generalist principles. OBJECTIVE OF PROGRAM: To quantify the generalism principles present in undergraduate medical education learning materials and to provide recommendations to enhance generalism content. PROGRAM DESCRIPTION: A review of the literature and accreditation documents was conducted to identify key elements of medical generalism. An evidence-informed tool, the Toronto Generalism Assessment Tool, was developed and applied to the new preclerkship undergraduate cases at the University of Toronto in Ontario. The findings regarding the presence of generalism principles and recommendations to enhance generalism content were provided to case developers. The recommendations were valued and were incorporated into subsequent iterations of the cases. CONCLUSION: This is the first report of a successful evidence-informed program to assess the degree of generalism reflected in undergraduate medical education curricular documents. This program can be used by other institutions wishing to review their curricula through a generalist lens.

Re-envisioning paradigms of education: towards awareness, alignment, and pluralism.

In this article we introduce a synthesis of education "paradigms," adapted from a multi-disciplinary body of literature and tailored to health professions education (HPE). Each paradigm involves a particular perspective on the purpose of education, the nature of knowledge, what knowledge is valued and included in the curriculum, what it means to learn and how learning is assessed, and the roles of teachers and learners in the learning process. We aim to foster awareness of how these different paradigms look in practice and to illustrate the importance of alignment between teaching, learning and assessment practices with paradigmatic values and assumptions. Finally, we advocate for a pluralistic approach that purposefully and meaningfully integrates paradigms of education, enhancing our ability to drive quality in HPE.

The myth of ivory tower versus practice-oriented research: A systematic review of randomised studies in medical education.

CONTEXT: A long-standing myth in medical education research is a divide between two different poles: research aiming to advance theory with little focus on practical applications ('ivory tower' research) and practically oriented research aiming to serve educators and decision-makers with little focus on advancing theory ('in-the-trenches' practice). We explored this myth in a sample of randomised medical education studies using Stokes' four-quadrant framework for the classification of research perspective. METHODS: We searched MEDLINE, Embase, CINAHL, PsychINFO, ERIC, Web of Science and Scopus for studies in medical education using a randomised design that were published between 1 January 2018 and 31 December 2018. We used Stokes' four-quadrant framework to categorise the studies according to their use of theory, concepts and their justification for practical use. We compared medical education research published in medical education journals and clinical journals. RESULTS: A total of 150 randomised studies were included in the analysis. The largest segment of studies (46.7%) was categorised as use-inspired basic research (Pasteur's Quadrant), closely followed by pure applied research (40.7%, Edison's Quadrant). Only a few studies were categorised as aiming to advance knowledge with no thought for practical educational application (2.0%, Bohr's Quadrant). The proportion of studies that included educational concepts and theory differed according to publication in clinical journals or medical education journals: 40.5% vs 71.8%, respectively, P < .001. There were no differences between journals with regard to the proportion of studies that included a practical educational or clinical rationale (P = .99). CONCLUSION: In a large sample of studies using randomised designs, we found no evidence to support the myth that medical education research divides between two singular poles represented by 'ivory tower research' and 'in-the-trenches practice'. We did confirm prevailing assumptions regarding an emphasis on non-theoretical medical education research in clinical journals.

Exploring why we learn from productive failure: insights from the cognitive and learning sciences.

Advances in Health Sciences Education (AHSE) has been at the forefront of the cognitive wave in health professions education for the past 25 years. One example is research on productive failure, a teaching strategy that asks learners to attempt to generate solutions to difficult problems before receiving instruction. This study compared the effectiveness of productive failure with indirect failure to further characterize the underpinning cognitive mechanisms of productive failure. Year one pharmacy students (N = 42) were randomly assigned to a productive failure or an indirect failure learning condition. The problem of estimating renal function based on serum creatinine was described to participants in the productive failure learning condition, who were then asked to generate a solution. Participants in the indirect failure condition learned about the same problem and were given incorrect solutions that other students had created, as well as the Cockcroft-Gault formula, and asked to compare and contrast the equations. Immediately thereafter all participants completed a series of tests designed to assess acquisition, application, and preparation for future learning (PFL). The tests were repeated after a 1-week delay. Participants in the productive failure condition outperformed those in the indirect failure condition, both on the immediate PFL assessment, and after a 1-week delay. These results emphasize the crucial role of generation in learning. When preparing novice students to learn new knowledge in the future, generating solutions to problems prior to instruction may be more effective than simply learning about someone else's mistakes. Struggle and failure are most productive when experienced personally by a learner because it requires the learner to engage in generation, which deepens conceptual understanding.

Reconsidering Basic: Integrating Social and Behavioral Sciences to Support Learning.

PURPOSE: The integration of basic science mechanistic knowledge (pathophysiology and etiology) with clinical features (signs and symptoms) during learning leads to robust cognitive representations in novices and supports the development of clinical reasoning, including better diagnostic accuracy and later learning of related concepts. However, previous studies have used a limited scope of traditional biomedical sciences, including biochemistry, anatomy, and physiology. The use of extended forms of foundational knowledge, including behavioral and sociological sciences, that have been proposed to support learning and performance in complex health systems remains unexplored. METHOD: Thirty-three first-year medical students from the University of Toronto MD Program participated in the study. The effect of integrated extended basic science (EBS) learning was compared with that of clinically focused instruction on an initial assessment of diagnosis using clinical vignettes and a "preparation for future learning" assessment (PFLA) to assess learning of new related content in medical psychiatry (co-occurring physical and mental health conditions). RESULTS: Both forms of instruction supported the development of diagnostic ability on initial assessment (t[30] = 1.20, P = .24). On the PFLA, integrated instruction of extended forms of basic science led to superior performance on assessing complex patients' health care needs (t[30] = 2.70, P < .05). CONCLUSIONS: Similar to previous studies using integration of biomedical sciences, the integration of EBS can enhance later learning of new related concepts. These results have implications for curriculum design to support development of expert clinical reasoning.

Productive failure as an instructional approach to promote future learning.

Productive failure is an instructional approach that requires learners to struggle as they attempt to generate solutions to problems before, rather than after, receiving direct instruction on a targeted concept. Studies demonstrate that productive failure prepares students for later learning of new, related knowledge. Our study explored the effectiveness of productive failure as an instructional intervention in health professions education with respect to (a) acquisition and application of a novel concept, and (b) learners' preparation for future learning of new, related content. Forty year-one students enrolled in the Doctor of Pharmacy program at the University of Toronto were randomly assigned to a productive failure (i.e. attempt to generate solutions before receiving instruction) or direct instruction only learning condition. After a practice phase, participants completed a series of tests designed to measure knowledge acquisition, knowledge application, and preparation for future learning (new learning is required for successful problem solving). As expected, no difference in performance was seen between participants on the acquisition and application tests. However, participants in the productive failure condition outperformed those in the direct instruction condition on the preparation for future learning test. These results emphasize the role of struggle in learning and support the theory that engaging students in solving problems that are beyond their abilities can be a productive exercise in failure. The results suggest that productive failure assists learners in acquiring the conceptual knowledge needed to facilitate learning in the future.

Critical Gaps in Understanding the Clinician-Scientist Workforce: Results of an International Expert Meeting.

Clinician-scientists-health care professionals expert in research and clinical practice-can play a vital role in translating research outcomes to clinical practice. Concerns about the sustainability of the clinician-scientist workforce have been expressed in the literature for decades. Although many have made recommendations to increase the clinician-scientist workforce, there has been no substantial change. Therefore, an international expert meeting was held in March 2017 in Utrecht, the Netherlands, with the goal of discovering unidentified gaps in our understanding of challenges to the sustainability of the clinician-scientist workforce. Nineteen individuals (steering committee members; representatives from the AAMC, AFMC, and RCPSC; and physician-scientists, nurse-scientists, education scientists, deans, vice deans, undergraduate and postgraduate program directors, and a medical student) from Canada, the Netherlands, the United States, and Singapore participated in the meeting. The meeting identified 3 critical questions to be addressed: (1) What is the particular nature of the clinician-scientist role? (2) How are clinician-scientists to be recognized within the health and health research ecosystem? and (3) How can the value that clinician-scientists add to translational medicine and research be clarified to stakeholders and the public? The meeting participants identified a 3-fold agenda to address these questions: articulating the value proposition of clinician-scientists, supporting professionalization and professional identity development, and integrating clinical and research training. Addressing the 3 critical questions will likely contribute to a wider recognition of the value of clinician-scientists and be a first step in advancing from recommendations toward system-level changes to reinvigorate the clinician-scientist workforce.

Why Content and Cognition Matter: Integrating Conceptual Knowledge to Support Simulation-Based Procedural Skills Transfer.

BACKGROUND: Curricular constraints require being selective about the type of content trainees practice in their formal training. Teaching trainees procedural knowledge about "how" to perform steps of a skill along with conceptual knowledge about "why" each step is performed can support skill retention and transfer (i.e., the ability to adapt knowledge to novel problems). However, how best to organize how and why content for procedural skills training is unknown. OBJECTIVES: We examined the impact of different approaches to integrating why and how content on trainees' skill retention and transfer of simulation-based lumbar puncture (LP). DESIGN AND PARTICIPANTS: We randomized medical students (N = 66) to practice LP for 1 h using one of three videos. One video presented only the how content for LP (Procedural Only). Two other videos presented how and why content (e.g., anatomy) in two ways: Integrated in Sequence, with why content followed by how content, or Integrated for Causation, with how and why content integrated throughout. MAIN MEASURES: Pairs of blinded raters scored participants' retention and transfer LP performances on a global rating scale (GRS), and written tests assessed participants' procedural and conceptual knowledge. KEY RESULTS: Simple mediation regression analyses showed that participants receiving an integrated instructional video performed significantly better on transfer through their intervention's positive impact on conceptual knowledge (all p < 0.01). Further, the Integrated for Causation group performed significantly better on transfer than the Integrated in Sequence group (p < 0.01), again mediated by improved conceptual knowledge. We observed no mediation of participants' skill retention (all p > 0.01). CONCLUSIONS: When teaching supports cognitive integration of how and why content, trainees are able to transfer learning to new problems because of their improved conceptual understanding. Instructional designs for procedural skills that integrate how and why content can help educators optimize what trainees learn from each repetition of practice.

Twelve tips for designing curricula that support the development of adaptive expertise.

An essential component of expertise is a clinician's ability to adapt to uncertain, complex, or novel situations while maintaining their competence in routine situations. Adaptive expertise provides a framework for understanding and developing experts who have the skills to effectively balance and support these dimensions of work using both procedural and conceptual knowledge. It is important for educators to understand that often the training which fosters adaptive expertise does not require new tools or approaches, but rather a reconceptualization of training using many of the same instruction and assessment formats already available. The twelve tips discussed in this paper showcase ways in which education can be transformed to support the development of adaptive expertise including the significance of instruction that combines various forms for knowledge, the value of productive struggle, and shifting the design of assessments to support learning and performance beyond retention and direct application.

Developing the experts we need: Fostering adaptive expertise through education.

In this era of increasing complexity, there is a growing gap between what we need our medical experts to do and the training we provide them. While medical education has a long history of being guided by theories of expertise to inform curriculum design and implementation, the theories that currently underpin our educational programs do not account for the expertise necessary for excellence in the changing health care context. The more comprehensive view of expertise gained by research on both clinical reasoning and adaptive expertise provides a useful framing for re-shaping physician education, placing emphasis on the training of clinicians who will be adaptive experts. That is, have both the ability to apply their extensive knowledge base as well as create new knowledge as dictated by patient needs and context. Three key educational approaches have been shown to foster the development of adaptive expertise: learning that emphasizes understanding, providing students with opportunities to embrace struggle and discovery in their learning, and maximizing variation in the teaching of clinical concepts. There is solid evidence that a commitment to these educational approaches can help medical educators to set trainees on the path towards adaptive expertise.