Clearing the confusion about post-accreditation monitoring, meta-evaluation and meta-accreditation.

We have recently published the experience of the accreditation body of undergraduate medical education in Iran on developing and validating standards based on the WFME framework (Gandomkar et al., BMC Med Educ 23:379, 2023). Agabagheri et al. extended our work and proposed a blueprint for post-accreditation monitoring based on their experience in developing an official guide in their Matters Arising (Aghabagheri et al., BMC Med Educ). The authors have used post-accreditation monitoring as a process of monitoring and controlling accreditation activities, procedures often referred to as meta-evaluation or meta-accreditation (depending on the objectives of evaluation) in the literature. On the contrary, post-accreditation monitoring alludes to the process of continuous quality improvement of educational programs after accreditation. We would like to make clarifications between post-accreditation monitoring, meta-evaluation and meta-accreditation which have been used interchangeably in their paper. Considering the emerging interests in scholarship and non-scholarship activities and reports in undergraduate medical education accreditation, this clarification provides a better understanding of the roles of these crucial concepts in the accreditation process.

Medical school department chair performance improvement: A qualitative study.

INTRODUCTION: In medical education, department chairs should play a significant role. The present qualitative study was conducted to identify factors that influence the performance improvement of department chairs at medical schools in Iran. METHODS: The study was conducted in Iran in 2022 and used a thematic analysis method. Using a purposeful sampling method, 20 participants were invited to participate, including medical school deans and department chairs. Focus group discussion (FGD) was used for qualitative data gathering. Braun and Clarke's thematic analysis was used to analyze data. RESULTS: There were 18 males and 2 females among the participants. The mean age of the participants was 45±4 years. Five overarching themes were formulated: human resource management, organizational behavior management, performance support system, leadership, and financial resources. Also, nine subthemes emerged, including performance evaluation, job and work design, educational and non-educational support, motivational efforts, organization culture, organizational knowledge management, planning for change, and financing. CONCLUSIONS: In this study, we found factors influencing DC performance improvement. Department chairs' effective performance may have a positive impact on department operations, processes, or outcomes.

Attitudes toward learning communication skills among Iranian medical students.

BACKGROUND: Attitudes determine behavior, and alterations in attitude may result in behavioral changes. Medical students would benefit from learning communication skills. This study aimed to determine the attitude of medical students toward the importance of learning communication skills and the training courses and their role in contributing. METHODS: In this cross-sectional study, 442 medical students from three different levels of medical training were enrolled. Students in the first 4 years of the medical program were classified as basic sciences and physiopathology students, those in the fifth and sixth years were classified as clerkship students, and those in the last three terms of medical training were classified as interns. The attitude among these three groups was assessed by the Communication Skills Attitude Scale (CSAS) questionnaire, and the contributing factors were determined. RESULTS: The mean total points for attitude in positive and negative aspects were 50.7 and 30.9, respectively showing a positive attitude toward communication skills among medical students. The median scores of the scales Important in Medical Content, Excuse, Learning, and Overconfidence varied significantly from highest to lowest, respectively. Gender, educational level, ethnic origin, language, family burden, paternal literacy, history of presence in communication skills courses, self-report from communication skills, and need to further learning in this era showed significant association with attitude (P < 0.05). CONCLUSIONS: It may be concluded that generally, medical students have a positive attitude toward communication skills, and this perspective is a multi-factorial entity that programming according to the various related factors would help to attainment of additional communication capabilities among medical students.

Developing and validating a national set of standards for undergraduate medical education using the WFME framework: the experience of an accreditation system in Iran.

BACKGROUND: Defining standards is the first step toward quality assurance and improvement of educational programs. This study aimed at developing and validating a set of national standards for the Undergraduate Medical Education (UME) program through an accreditation system in Iran using the World Federation for Medical Education (WFME) framework. METHODS: The first draft of standards was prepared through consultative workshops with the participation of different UME program stakeholders. Subsequently, standards were sent to medical schools and UME directors were asked to complete a web-based survey. The content validity index at the item level (I-CVI) was computed using criteria including clarity, relevance, optimization and evaluability for each standard. Afterward, a full-day consultative workshop was held and a wide range of UME stakeholders across the country (n = 150) discussed the survey results and made corrections to standards. RESULTS: Analysis of survey results showed that relevance criteria had the best CVI as only 15 (13%) standards demonstrated CVI < 0.78. More than two-thirds (71%) and a half (55%) of standards showed CVI < 0.78 for optimization and evaluability criteria. The final set of UME national standards was structured in 9 areas, 24 sub-areas, 82 basic and 40 quality development standards, and 84 annotations. CONCLUSIONS: We developed and validated national standards as a framework to ensure the quality of UME training with input from UME stakeholders. We used WFME standards as a benchmark while addressing local requirements. The standards and participatory approach to developing standards may guide relevant institutions.

Educational content of professional ethics in postgraduate dental education.

PURPOSE: Inclusion of proper educational content with respect to professional ethics in dental curricula is an important step to achieve objectives of ethics education especially in postgraduate programs when the time and opportunities for explicit instruction of ethics are limited. This study aimed to find and discuss the topics of ethics and professionalism for dental postgraduate programs. METHODS: A modified Delphi survey of experts' opinions with three rounds was conducted to establish a consensus on the need to teach professional ethics topics. The topics were identified through a literature review and according to the opinion of the experts. Items scored as highly important by over 80% of the participants in each round of the survey were considered educational needs. RESULTS: A total of 154 ethical issues were identified and classified into 29 topical categories to design the initial questionnaire. A consensus was developed on 24 ethics and professionalism topics for inclusion in the professional ethics curriculum for all dental postgraduate programs. CONCLUSIONS: Based on the results of this study, the same educational content in professional ethics is needed for all dental residency programs in all specialties. Most of the topics on which experts reached a consensus to be included in the ethics educational content were related to ethical and professional standards of conduct.

What we think about professional and unprofessional behaviors: differences between the perception of clinical faculty members and medical students.

INTRODUCTION: Differences in the viewpoints of clinical faculty members and medical students about prioritizing professional norms accepted by the professional community and lack of alignment of these views can lead to distortion of understanding, problems in learning and assessment of professionalism, and failure in students' professional identity formation. This study aimed to identify the differences in viewpoints of clinical faculty members and medical students about prioritizing the importance and prevalence of professional and unprofessional behaviors among undergraduate medical students. METHODS: A multi-stage qualitative study was conducted at Tehran University of Medical Sciences during 2020-2021. At first, a systematic search was conducted to identify professional and unprofessional behaviors using the directional content analysis method. A panel of experts was formed to check the codes obtained from reviewing the literature and to evaluate its compliance with the context. Then, the modified nominal group technique sessions were held with clinical faculty members and medical students to strengthen the codes extracted from the studies and systematically integrate their views to achieve a comprehensive list of professional and unprofessional behaviors in accordance with the context. Finally, a consensus was made among them about prioritizing the importance and prevalence of these behaviors in undergraduate medical students. RESULTS: A total of 490 codes of professional behaviors and 595 unprofessional behavior codes were identified in the literature review. In the following sessions of the modified nominal group, 13 clinical faculty members listed 105 codes of professional and unprofessional behaviors, and 51 medical students also listed 313 codes. The results of the modified nominal group technique showed that the faculty members reported the importance of unprofessional behaviors higher than professional ones. At the same time, students rated the importance of professional behaviors higher than unprofessional ones. Both faculty members and students rate the prevalence of professional behaviors as high and the prevalence of unprofessional behaviors as low. CONCLUSION: The results showed a difference of views between clinical faculty members and medical students about prioritizing professional and unprofessional behaviors. It is essential to align their viewpoints to understand, learn and value professionalism to develop a professional identity.

Transfer of learning from simulated setting to the clinical setting: identifying instructional design features.

Background: Transfer of learning (ToL) is the endpoint of simulation-based training (SBT). It is affected by numerous factors, which can be classified into 3 categories: learner characteristics, work environment, and training design. The first 2 have been identified to some extent in previous research. In this study, the aim was to identify the instructional design (ID) features affecting the ToL in SBT. Methods: This qualitative study was conducted in 2 phases. Phase 1 covers thematic analysis of comparative studies in the field of SBT. A systematic search was performed on 6 databases of Ovid MEDLINE, EMBASE, PsycINFO, CENTRAL, Scopus, and Web of Science, and the references of related systematic reviews were also checked. In phase 2, semi-structured interviews were conducted with key informants (instructors and learners) and analyzed using directed content analysis. The results of the 2 phases were combined, and finally ID features of SBT were identified and categorized. Results: In the first phase, 121 comparative studies were reviewed and in the second phase, 17 key informants were interviewed. After combining the results of the phases, the ID features affecting the ToL in SBT were classified into 3 broad categories and 15 subcategories as follows: (1) presimulation: preparation, briefing, and teaching cognitive base; (2) underlying theories: deliberate practice, mastery learning, and proficiency-based training; (3) and methods and techniques: distributed practice, variability, increasing complexity, opportunity for practice, repetitive practice, active learning, feedback/debriefing, simulator type, and simulator fidelity. Conclusion: Although learning is transferred from the simulated setting to the clinical setting, this process is not automatic and straightforward. Numerous factors affect this transfer. The results of this research can be used in designing and evaluating the SBT programs.

Clinical teachers' perceptions of role modeling: a qualitative study.

BACKGROUND: Role modeling has been significantly considered in medical education in recent decades. In the clinical course, students learn necessary skills and accordingly their professional identity is formed by observing and working among clinical educators. Given the importance of the role modeling in medical education, in the present study, it was attempted to explore the clinical teachers' perceptions of being a role model for medical students using a qualitative method. METHODS: A qualitative design, based on the content analysis approach, was used to analyze the perspectives of 15 clinical teachers. Participants were chosen by purposeful sampling. Data were collected using reflection paper writing. RESULTS: During the data analysis, five main categories emerged: influencing others, developing different dimensions of student, situational self-awareness, feedback and continuous effort. CONCLUSIONS: This study will be useful to form role modeling educational programs. Encouraging clinical teachers to make continuous efforts to improve role modeling and educating time management and self-control skills can help reduce the challenges of role modeling for clinical teachers.

Exploring clinical educators' perceptions of role modeling after participating in a role modeling educational program.

INTRODUCTION: Role modeling significantly affects medical students' values, attitudes, and professional behaviors. Role modeling is a complex and multidimensional process that necessitates accurate perception and adequate knowledge and skills. However, most clinical educators do not have adequate awareness and knowledge about the positive and negative effects of role modeling. We aimed to explore clinical educators' perceptions of role modeling after participating in a role modeling educational program. METHODS: This qualitative study was conducted on eighteen clinical educators who were voluntarily participated in a three-month role modeling educational program. Data were collected using reflection paper writing and were analyzed through conventional content analysis. RESULTS: Data analysis resulted in the development of three main categories, namely closer attention to role modeling and effort for its promotion, deliberate effort to display role modeling, and creating a positive environment to increase the effectiveness of role modeling. CONCLUSIONS: Clinical educators have limited role modeling knowledge and skills, and hence, educational programs are required to improve their role modeling knowledge, attitudes, and skills. Role modeling educational programs should aim at developing educators' awareness and knowledge about role modeling, develop their reflection and self-control abilities, and sensitize them to the importance of deliberate use of role modeling.

Accountability in medical education from theory to practice Tabriz 2018 statement: A step towards the implementation of this social necessity.

Background: To implement the education reform package on accountability in medical education, the Education Development Center (EDC) of Tabriz University of Medical Sciences has held the first national conference on accountability in medical education, and the present statement is the result of scientific interactions and exchanges in the conference. Methods: For implementation of the accountability in medical education, there was a need to inform faculty members and other stakeholders about their responsibility in education and health care needs. The provision of such platform was provided by holding a specialized conference on accountability in medical education by Tabriz University of Medical Sciences. Steps of preparing the draft version of the Tabriz 2018 Statement were as follow: Formation the scientific committee; Division of the responsibility for drafting the statement between various workgroups; and Preparation and primary approval of the draft of Tabriz 2018 Statement. Results: Steps of preparing the draft version of the Tabriz 2018 Statement were: Formation of the scientific committee, Division of the responsibility for drafting the statement between the various workgroups and Preparation and primary approval of the draft of Tabriz 2018 Statement. Conclusion: Establishing an educational accreditation model and reviewing accreditation standards based on social accountability can be an effective step to strengthen accountability towards community needs.

Turning unprofessional behaviors around using Holmes' reflection approach: a randomized controlled study.

Many medical schools around the world have included professionalism training in their formal curriculum. However, these efforts may not be adequate; given the exposure of students to unprofessional behaviors in the clinical settings. In the present study, we aimed to design, implement, and evaluate a longitudinal program to improve professionalism among medical students upon their transition to clinical settings. A total of 75 medical students were enrolled in the study and randomly assigned to two groups. The control group did not receive any training, while for the intervention group; a 10-hour program through 16 weeks was organized based on the Holmes' reflection approach. The effectiveness of the program was evaluated by measuring three outcomes in both groups. Data analysis was performed using paired t-test and Multiple Linear Regression. Scores of judgment of professionalism increased in the intervention group (from 7.56 to 10.17; P< 0.001), while there was no significant improvement in the control group's scores. Students' attitudes towards professionalism and their professional behaviors did not change significantly. Based on our findings, the Holmes reflection approach helps students improve their cognitive base of professionalism. Long-term follow-up and further qualitative studies will help us better understand the effects of this approach on other desirable outcomes.

Psychometric evaluation of a questionnaire to evaluate organizational capacity development for faculty development programs.

BACKGROUND: Organizational capacity development is an important outcome of faculty development programs, but there is a lack of an appropriate instrument for its evaluation. AIMS AND OBJECTIVES: The aim of this study was to develop a questionnaire to evaluate the organizational capacity development for faculty development programs and to test its psychometrics. MATERIALS AND METHODS: The initial capacity development for faculty development questionnaire (CDQ-FD) of 26 items was developed based on a literature review and opinion of experts. Content validity ratio (CVR), content validity index (CVI), content validity index for items (I-CVI), and the content validity index for scales (S-CVI) were computed for content validity. Confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were performed for construct validation. RESULTS: The score for CVR, CVI, I-CVI, and S-CVI was 0.71, 0.83, 0.87, and 0.90, respectively. EFA resulted in a three-factor model with total variance extraction of 64%. Cronbach's alpha and Spearman Brown coefficient were investigated for reliability assessment. The Cronbach's alpha of overall scale was 0.8 and the test-retest reliability of the overall scale was 0.78. The final CDQ-FD contained 21 items and three categories. CONCLUSIONS: The CDQ-FD questionnaire appears to be a valid and reliable instrument for the evaluation of organizational capacity development for faculty development in the medical education.

Twelve Lessons on Hospital Leadership during COVID-19 Pandemic.

Coronavirus pandemic has been announced by World Health Organization Director General on March 11th, 2020. Imam Khomeini Hospital Complex, affiliated to Tehran University of Medical Sciences, was one the first referral hospitals in the capital city of Tehran, I.R.Iran that entered the crisis and started a serious battle with the disease. The hospital had to change many routine operations to cope with the situation and during this journey, we used published leadership principles and reached to some new experiences. As this is probably the most severe health-related crisis in Iran in the past 100 years, we gathered our lessons learned in the first fifty days of epidemic from the leadership point of view to share those with all colleagues worldwide. We know that leadership is of pivotal role in such a massive crisis and focused leadership experiences can help health care providers to manage the crisis while we are in the middle of it.

Identification of capacity development indicators for faculty development programs: A nominal group technique study.

BACKGROUND: Although there have been many research studies of the effectiveness of faculty development in health profession education, the contribution of these programs to organizational development through capacity development has not been studied. Further understanding of capacity development requires appropriate indicators and no previous indicators for faculty development of health profession educators were identified. The aim of the study was to identify indicators of capacity development in the context of faculty development programs at Tehran University of medical sciences (TUMS). METHODS: A nominal group technique session was conducted with key informants from faculty development program providers to generate and prioritize a list of capacity development indicators. RESULTS: A list of 26 indicators was generated and five categories were identified: Development and innovation in teaching and learning process, Development and innovation in communication and collaboration at different levels, Development and sustaining faculty development programs, Development of educational leadership and management, Development in scholarship. CONCLUSIONS: Capacity development for faculty development interventions of health profession educators is a process of engagement within a wider system, including individual and collective action, and involves the socialization of the teachers into suitable roles through professional identity development and participation within the wider system.

Using multiple self-regulated learning measures to understand medical students' biomedical science learning.

CONTEXT: Understanding self-regulated learning (SRL) is complicated due to the different measures used to identify the key SRL processes. There is a growing trend in applying event measures of SRL (microanalysis and trace) but aptitude measures (questionnaires) continue to be widely used in medical education. A major concern is whether aptitude measures are a valid approach to capture the dimensions of SRL processes. This study examined correlations between SRL microanalysis, SRL trace and the Motivated Strategies for Learning Questionnaire (MSLQ) and how these measures were associated with biomedical science performance. METHODS: An SRL microanalysis assessment interview was administered to 76 first-year medical students individually when performing a biomedical science learning task. All written materials by students were collected for further trace analysis. Students completed an MSLQ 2 weeks before completing their biomedical science course. Correlation analyses were used to determine the correlations between the three SRL assessment measures. Bivariate and multiple analyses were conducted to compare students on different course or task performance using the three SRL assessment measures. RESULTS: Microanalytic metacognitive monitoring (κ = 0.30, P < .001) and causal attributions (κ = 0.17, P = .009) had statistically significant correlations with use of the SRL trace strategy. MSLQ self-efficacy correlated with microanalytic self-efficacy (r = .39, P = .001). Bivariate tests showed that microanalytic metacognitive monitoring, causal attributions and adaptive inferences, and SRL trace strategy use had significant associations with task performance (P < .05). Microanalytic self-efficacy, metacognitive monitoring and causal attributions, SRL trace strategy use and MSLQ self-efficacy had significant associations with course performance (P < .05). Measures of use of the SRL trace strategy and MSLQ subscales did not show significant associations with task and course outcomes in multiple analyses (P > .05). CONCLUSIONS: Event measures, specifically SRL microanalysis, had greater associations with both task and course outcomes compared with the MSLQ measure. The SRL microanalysis is recommended for the assessment of SRL in biomedical science learning. However, to fully understand medical students' SRL a multidimensional assessment approach that combines event and aptitude measures should be used.

Improving Role Modeling in Clinical Teachers: A Narrative Literature Review.

INTRODUCTION: Students observe role models and learn from them in a variety of educational settings. Although it is known that role models impact on professional and character development of students, some clinical teachers are poor role models. We conducted a review to summarize evidence that could help clinical teachers promote their role modeling. METHODS: We performed a review search and by using specific keywords (curriculum, role model*, faculty development, teach*, program* and education), through electronic databases (PubMed, EMBASE, and ERIC). We obtained 320 qualitative and quantitative studies. Having removed the duplicate references, we read 244 titles and excluded irrelevant ones. Eighty-two articles were retained and the abstract of each was read. Finally, 20 articles were included. RESULTS: According to the results of our review, three major themes were identified: 1) features of a good role model composed of teaching, clinical, and personal-interpersonal skills 2) self-improvement of role modeling, and 3) faculty development programs. CONCLUSIONS: Role models have a profound effect on the attitudes and behaviors of medical students. It is important for clinical teachers to make an intentional effort to articulate what aspects they are modeling. This study can help faculty members be an effective role model. Also, finding of this review could form the foundation of a faculty development program in order to foster role modeling in clinical settings.

Enhancement of role modelling in clinical educators: A randomized controlled trial.

Introduction: Role models have an important impact on the professional behavior of medical students. Previous investigations help us understand how to improve role modelling. However, studies aiming at enhancing role modelling among clinical educators are very limited and generally lack comprehensive evaluations of the designed programs. We intended to gather robust evidence on the effectiveness of a longitudinal program for enhancing role modelling.Methods: Clinical educators were divided into intervention and control groups. The longitudinal program, developed based on the exposure phase of the 'Positive Doctor Role Modelling' framework, was delivered during three months of onsite and online sessions. The effectiveness of the program was assessed in three levels of reaction, learning, and behavior.Results: In the intervention group (N = 18), the mean score of satisfaction was 4.7 (SD = 0.5), and the learning (awareness about role modelling) improved significantly after the program (3.33-4.34), comparing to the control group (3.53-3.63). There was no significant difference in terms of behavior improvement between the two groups, before and after the program.Conclusions: Our findings indicate that our longitudinal faculty development program on role modelling was highly appreciated by clinical educators, and improved their awareness and deliberate role modelling.

Validating Self-Reflection and Insight Scale to Measure readiness for Self-Regulated Learning.

BACKGROUND: Professional behavior of physicians is under scrutiny by medical associations, media, and patients; therefore, medical students are expected to be self-directed learners rather than the passive ones. One of the useful strategies for professional development and life-long learning of students is self-regulated learning. Self-regulation concept and lifelong learning commitment are in the heart of medical practice. Therefore, this study aimed to evaluate the validity of Self-Reflection and Insight Scale (SRIS) to inspect the medical students' readiness for self-regulation. MATERIALS AND METHODS: SRIS was translated according to the Sousa and Rojjanasrirat guideline. To examine the reliability and validity evidence of the scale, 136 medical students from Tehran University of Medical Sciences completed the questionnaire. Internal consistency and intraclass correlation were used to examine the reliability evidence, as well as qualitative content validity, and confirmatory factor analysis and exploratory factor analysis (EFA) were used to examine the construct validity of the scale. RESULTS: The content validity of the scale was verified. Cronbach's alpha and the Interclass Correlation Coefficient value for the four-factor model was 0.87 and 0.79, respectively. Goodness-of-fit indices displayed acceptable and poor values (P = 0.0001, χ2 = 373.51, df = 167, Root Mean Square Error Of Approximation = 0.096, standardized root mean square residual = 0.12). EFA was conducted; a well-structured model was achieved through the EFA. The new four-factor model was extracted as the best model by performing EFA. CONCLUSION: SRIS Persian version is saturated with four factors and has desirable content validity and constructs reliability.

Developing a competency framework for Health Professions Education at doctoral level: The first step toward a competency based education.

Introduction: The aim of this study was to develop the competency framework for Doctoral graduates in Health Professions Education, which is the first step in implementing an outcome-based curriculum. Method: The present study conducted in three phases. First, viewpoints of 100 stakeholders, including students, graduates, faculty members, and educational managers were explored by using Nominal Group technique, survey, and telephone interviews. The extracted codes classified in subcategories and categories through an inductive content analysis approach. In phase two, the findings converted to competency components, sub-domains and competency domains in working groups. Finally, the content validity of the developed components evaluated through qualitative and quantitative approaches. Results: 535 codes, 12 sub-categories, and 7 categories extracted from stakeholders' viewpoints, which were refined to 65 competency components, 12 sub-domains and 7 competency domains in working groups. The final competency framework includes 54 competency components in seven competency domains of a "professional expert", "research and scholarship", "teaching", "interdisciplinary collaboration", "leadership and management", "professionalism", "personal and professional development". Conclusion: Competency framework is essential for the development of a comprehensive and integrated curriculum. It would be possible to implement a competency-based curriculum in the Doctoral program of Health Professions Education by developing the competency framework.