Tangrams: a simple visual tool for communicating the complexities of professionalism.

Professionalism is vital for high quality healthcare and fundamental to health profession education. It is however complex, hard to define and can be challenging to teach, learn about and assess. We describe the development and use of an innovative visual tool, using a tangram analogy, to introduce and explore core professionalism concepts, which are often troublesome for both learners and educators. These include the hidden curriculum, capability, professional identity and the difference between unprofessionalism and high professional standards.  Understanding these concepts can help individuals to see professionalism differently, encourage faculty to design professionalism programmes which focus on professional excellence, support assessors to feel more confident in identifying and addressing underperformance and facilitate learners to appreciate the complexity and uncertainty inherent in professionalism and to become more alert to the hidden curriculum and its potential impact. We have used the tangram model to educate for professionalism in multiple contexts with learners and educators. Participants regularly report that it leads to a deeper understanding and important new insights around professionalism and helps them identify ways of changing their practice.  We believe this approach has relevance across the health professions and suggest ways it could be further developed to explore wider professionalism issues such as reflective practice, resilience and teamworking.

GP trainee responses to using SHERPA for multimorbidity consultations.

UK general practitioner (GP) trainees are taught a consultation model which elicits the patients' main reason for consulting 'today'. This approach will often miss important issues for the increasing number of patients with multimorbidity. We developed the SHERPA model as a person-centred biopsychosocial framework for consulting patients with multimorbidity to address this. We aimed to examine GPs trainees' responses to SHERPA when integrated into their vocational training. The research design was qualitative and participants were GPs trainees in vocational training from one UK training location. GP trainees were introduced to the SHERPA model through interactive workshops. Qualitative data were collected from 16 participants, through four hours of teaching observation, 24 feedback templates, six practical applications of SHERPA and eight one-to-one interviews. Data were transcribed, and, using the Framework approach, systematically analysed, focussing on trainees' learning and application of the model. The results demonstrated that all participants engaged well with the teaching sessions, brought observations from their own experience, and reflected on particularly complex consultations. Half of the participants applied SHERPA successfully with their patients, particularly repeat attenders. Barriers to this approach were: selecting appropriate patients; perceived time pressure; lack of familiarity using the model; viewing SHERPA as 'additional', rather than integral, to shared decision-making in complex situations. The SHERPA model was viewed as helpful by these GP trainees for patients with whom they had established a relationship. Earlier introduction and regular support from trainers, where trainees reflect on experience of SHERPA, could increase confidence in using this method.

Structured reflection on shared decision making.

BACKGROUND: Shared decision making (SDM), whereby patients and clinicians work collaboratively to make health care decisions, brings multiple benefits. It has, however, been slow to integrate into clinical practice. There are some examples of SDM being embedded and evaluated within medical undergraduate curricula but, despite role models being important in promoting students' patient-centred attitudes, these examples do not involve students reflecting on clinicians' use of SDM in practice. METHODS: We undertook a qualitative evaluation of a small group educational intervention. A key element was the students' use of a structured reflective template, drawing on the SHARE (seek, help, assess, reach, evaluate) SDM tool, to analyse examples of clinicians using SDM in practice critically. We undertook a thematic analysis of students' completed templates and evaluated their engagement with the SHARE tool. FINDINGS: A total of 44 templates were analysed. Four main themes were identified, including new learning about SDM, noticing and deconstructing SDM, participants' responses to SDM and struggles in learning. Students were positive about SHARE and used it to critique experiences and suggest specific ways that clinicians could have improved SDM. DISCUSSION: A structured training intervention that promotes critical reflection on clinical role models can help to shift undergraduate medical students' understanding of, and attitudes towards, SDM. The ethical arguments for SDM, evidence for its benefits and the alignment of SDM with participants' own core values appeared to help achieve student 'buy in'. Students struggled with notions of power, risk and time constraints, and empathised with both patients and clinicians. They highlighted the scarcity of SDM in practice.

'Today's shook me up a lot inside it's definitely changed me': emotional responses and transformative learning through working with disadvantaged communities.

BACKGROUND: While undergraduate curricula should reflect populations' priority health needs and promote social accountability, evidence about the impact of such interventions is limited. AIM: To gain insights into students' lived experiences of social engagement pathways and associated learning. METHOD: Medical and dental students spent four days with local organisations working with disadvantaged groups, recording audio-dairies after each session. These were transcribed, coded and analysed thematically. RESULTS: Fourteen students produced 50 audio-reflections. Key themes included emotions, learning and critical reflection. Students reported improved communication skills, better appreciation of others' lives and having their assumptions challenged. They questioned issues underpinning inequalities. Analysis revealed a three-act pathway structure, with students' emotional responses changing as projects progressed. DISCUSSION: Immersion in new contexts; connecting with others; having their views challenged and plans going wrong appeared to facilitate shifts in thinking, as did experiencing negative emotions. Feedback and support from organisations, facilitators and service users helped students overcome challenges, which was associated with positive emotion. CONCLUSION: Educators often work hard to make learning 'easier' for students. This study suggests that when exploring the social determinants of health within community settings, supporting students to experience such unsettling contexts and negative emotions may facilitate transformative learning.

Exploring threshold concepts in population health.

BACKGROUND: Doctors are increasingly expected to improve the health and well-being of populations, as well as to care for individuals. However, despite extensive efforts to integrate population health into undergraduate programmes, engaging students in such learning is notoriously challenging. Threshold concepts are transformative, integrative, irreversible and fundamental to understanding a discipline. Grasping such concepts requires learners to cross a liminal space, which often involves struggle. METHODS: We employed a form of transactional curriculum enquiry, involving qualitative and quantitative methods, with experienced population health medical educators to identify and explore threshold and troublesome concepts in population health. RESULTS: Attributing causality, inequalities in health and doctors' responsibility for populations not just individuals were the concepts most participants thought were threshold. The value of qualitative research, health as politically and socially determined and not taking evidence at face value were the concepts ranked as most troublesome for learners. Participants found the notions of threshold and troublesome concepts helpful and empowering. They described ways these new ideas would influence how they taught population health. DISCUSSION: Transactional curriculum enquiry can offer insights into which population health concepts may be threshold and troublesome. The number of such concepts identified in this study may help explain why students often struggle to engage in population health learning. Understanding which concepts are threshold and particularly which are troublesome can help teachers to better support learners and can also inform curriculum design. If our students are to … take responsibility for populations as well as individuals … it is vital that they cross these fundamental thresholds in learning.

A qualitative research synthesis exploring professional touch in healthcare practice using the threshold concept framework.

Touch is an integral part of human life. Consequently, touching and being touched are also fundamental to healthcare practice. Despite a significant literature on touch, it is rarely conceptualized or discussed in terms of the student journey from layperson to practitioner. We chose to explore professional touch using the threshold concepts framework (TCF), which provides a theoretical model for exploring the way in which learners encounter, engage with and understand fundamental concepts in a discipline. This qualitative research synthesis (QRS) describes the use of the TCF to identify key issues involved in developing and using professional touch. Through a cross-professional analysis and synthesis of recent international literature, we aimed to identify key characteristics of the transitional journey for professional touch. Three orders of analysis were applied, employing a methodology described by Major and Savin-Baden (An introduction to qualitative research synthesis: managing the information explosion in social science research, Routledge, London, 2010). Following identification of threshold characteristics in the overall sample of articles, second order analysis revealed the nuances of professional touch associated with the characteristics. The final synthesis led to identification of five themes: touch as dialogue; being changed by touch; multiple boundaries of touch; multiple meanings of touch and influences on touch. Whilst providing support for some assertions within the literature, this QRS also offers new insights into the complexity of professional touch. Given the paucity of explicit learning and reflection around professional touch in training programmes of health professionals, the TCF reveals ways in which professional preparation might be improved to promote understanding of the role and impact of touch in practice.

Learning to become a primary care professional: insights from threshold concept theory.

Threshold Concepts are fundamental ideas within a discipline which are transformative, integrative, irreversible and usually troublesome. This article describes the threshold concept framework and discusses how it can offer new insights into how we focus teaching and facilitate learning around these concepts, such as uncertainty. Relevant research from a range of health disciplines are explored to consider which concepts may be critical to thinking and practising effectively in primary care. In addition, it is proposed that threshold concepts may have relevance to the GP recruitment crisis.

Evaluation of an innovative, evidence-guided, PBL approach.

AIM: To understand the experiences of students and problem-based learning (PBL) facilitators during an evidence-based curriculum change to a PBL programme within an undergraduate medical course in South West England. METHODS: Four novel PBL cases were designed and implemented, based on educational theory and evidence. Eight focus groups were undertaken with Year-1 and -2 students (n = 18) and PBL facilitators (n = 14) to explore the experiences of participants. Thematic analysis and conceptual abstraction led to insights into the intended and unintended consequences of the change. RESULTS: Participant responses to the change process were influenced by the perceived relevance and value of the change (e.g. benefit to student learning), which was shaped by individual beliefs and preferences (e.g. presumed purpose of PBL, relative value placed on different curriculum topics, and desire for uniform educational experience), and the wider education context (e.g. expectations of assessment). It appears that the three distinct elements must align for the changes to be received positively. We updated our PBL curriculum in response to new evidence DISCUSSION: This study describes how we updated our PBL curriculum in response to new evidence, and demonstrates the importance of communicating the pedagogic rationale behind changes, and meticulous planning, preparation and alignment, even in distant parts of the curriculum. Engaging with existing views and attitudes is an essential requirement for successful curriculum change.

Empowering students with the hidden curriculum.

BACKGROUND: The hidden curriculum (HC) refers to unscripted, ad hoc learning that occurs outside the formal, taught curriculum and can have a powerful influence on the professional development of students. While this learning may be positive, it may conflict with that taught in the formal curriculum. Medical schools take a range of steps to address these negative effects; however, the existence and nature of the concept tends to be hidden from students. METHODS: Since 2007, our medical school has incorporated into its small group programme an educational activity exploring the concept of the hidden curriculum. We undertook a qualitative evaluation of our intervention, conducting a thematic analysis of students' wiki reflections about the HC. We also analysed students' responses to a short questionnaire about the educational approach used. FINDINGS: The majority of students felt that the HC session was important and relevant. Most appeared able to identify positive and negative HC experiences and consider how these might influence their learning and development, although a few students found the concept of the HC hard to grasp. DISCUSSION: Revealing and naming the hidden curriculum can make students aware of its existence and understand its potential impact. The hidden curriculum may also be a useful tool for triggering debate about issues such as power, patient centredness, personal resilience and career stereotypes in medicine. Supporting students to think critically about HC experiences may empower them to make active choices about which messages to take on board. The hidden curriculum can have a powerful influence on the professional development of students.

Twelve tips for promoting professionalism through reflective small group learning.

This article was migrated. The article was marked as recommended. The importance of placing small group learning at the heart of professionalism curricula is increasingly being recognised within undergraduate medical education. Facilitated small groups provide a valuable setting for students to reflect upon their experiences and to learn about broad aspects of professionalism. By better understanding relevant learning theory and evidence, we can identify approaches for increasing the effectiveness of such groups and overcoming potential barriers to learning. Training facilitators is a vital part of this process. The following tips are based on the literature and the authors' experiences of leading small group learning programmes in two UK medical schools. They provide guidance and ideas for designing an experiential small group learning programmed focused on professionalism and for supporting and training a team to facilitate effective learning in this setting.

Evaluating your professionalism.

What does being professional look like? Does it mean that you do the 'right' thing, even when no-one is looking? How do you evaluate your professionalism knowledge, values and behaviour? How do you identify and address underperformance in professionalism? How can you transfer your professionalism to different circumstances?

What are threshold concepts and how can they inform medical education?

The notion of "threshold concepts" is being widely applied and researched in many disciplines but is rarely discussed within medical education. This article is written by three medical educators who regularly draw on threshold concept theory in their work. They explore here the nature of threshold concepts and describe how the theory can offer medical educators new perspectives in terms of how they design curricula, approach teaching and support learners.