Understanding Residents' and Supervisors' Views on Developing Support-Autonomy Balance Through Supervision Methods in Postgraduate Dental Training: A Qualitative Study.

BACKGROUND: Supervisors continuously need to decide when to provide clinical opportunities for unsupervised patient care to facilitate residents' development in the complex clinical learning context. The aim of this study is to explore residents' and supervisors' views and understanding of the influence of clinical supervision on affording a balanced support-autonomy from the cognitive apprenticeship (CA) theoretical lens. METHODS: Residents and supervisors, representing all disciplines, participated in five focus groups and four semi-structured individual interviews. Purposive and convenience sampling methods were used for recruiting participants. The reflexive thematic analysis approach was used for inductive data analysis. RESULTS: A total of 15 residents and 8 supervisors participated in this study. All agreed that CA teaching methods can be applied across all levels. Participants experienced changes in their supervision methods and supervisor-resident interactions at different levels of training. They related the selection of supervision to task-, resident- and supervisor-related factors. Learning facilitating factors in clinical learning environment were identified and suggestions to enrich residents' learning experiences were also reported. CONCLUSION: The current study found that a one-size-fits-all paradigm may not be effective for clinical supervision. It contributes to our understanding of how the CA model may be used to guide supervisor behaviour and how such practices can be modified to residents' level of development and competencies.

Challenges Faced by Medical Trainees in Outpatient Management Education in Acute Care Hospitals: A Thematic Analysis.

Introduction As societies age globally, medical education faces the challenge of adapting to the evolving healthcare needs of an aging population. This study focuses on the education of medical residents in outpatient departments in Japan, a country with a rapidly aging society. The research aims to understand the perceptions and challenges medical residents face in outpatient management, highlighting the areas for potential improvement in their educational framework. Method This study involved first-year medical residents at Fuchu Hospital in Osaka, using thematic analysis based on relativist ontology and constructivist epistemology. Data were collected through field notes and reflection sheets, documenting residents' interactions with patients, learning difficulties, and personal reflections. Semi-structured interviews were conducted to gain profound insights into their experiences and views on outpatient management education. Results Three main themes emerged from the analysis: The experience of continuity of care, the view regarding comprehensive management, and the gap between purposes and learning content. Residents expressed concerns about the limited opportunities for continuous patient care, leading to challenges in managing chronic diseases effectively. The focus on organ-specific specialties in acute care hospitals resulted in a fragmented understanding of patient care, particularly for elderly patients with multimorbidity. Furthermore, the study identified a discrepancy between the educational goals of outpatient management and the actual content delivered, highlighting the need for more observational experiences and practical guidance in outpatient settings. Conclusion The findings suggest a pressing need for a more structured, comprehensive, and personalized approach to outpatient management education for medical residents. As aging populations continue to grow, it is vital to equip medical professionals with the skills and knowledge to manage a wide range of patient conditions effectively. Improving the educational framework in outpatient departments can enhance patient care quality and prepare medical residents to meet the challenges of an aging society. This study contributes valuable insights into improving medical education in outpatient settings, particularly in aging societies like Japan.

Investigating the role of clinical exposure on motivational self-regulation skills in medical students based on cognitive apprenticeship model.

BACKGROUND: The importance of motivation regulation in medical students is highly significant due to their unique educational circumstances, such as clinical exposure. However, the role of clinical exposure in learning motivational self-regulation skills in students has not been explored thus far. This current study aims to investigate the role of clinical exposure on motivational self-regulation skills in medical students based on cognitive apprenticeship model. METHOD: This study was descriptive-analytical research conducted in 2022 on medical students. Data collection involved two questionnaires including Meta motivational Strategies in Medical Students Questionnaire and Maastricht Clinical Teaching Questionnaire. The research comprised two stages including measuring motivational self-regulation strategies in students before entering the clinical exposure phase, and simultaneous measurement of clinical exposure based on the student's viewpoint and their motivational self-regulation strategies at the end of the first term of clinical exposure. RESULTS: The results revealed a significant relationship between six dimensions of the cognitive apprenticeship model, including modeling, coaching, scaffolding, reflection, exploration, and learning environment, with motivational self-regulation strategies. However, there was no significant relationship between the articulation dimension of the cognitive apprenticeship model and motivational self-regulation strategies. CONCLUSION: Clinical exposure indirectly enhances students' metacognitive skills. Observing the behavior of clinical faculty in the clinical exposure setting leads to the improvement of motivational self-regulation strategies in medical students.

The cognitive apprenticeship model as a framework for desired precepting qualities to inform preceptor development.

INTRODUCTION: Positive learner perceptions of learning experiences have been linked to better learning outcomes. More information is needed on learners' desired qualities of preceptors and learning experiences to inform preceptor development. Aligning learners' perceptions with a teaching framework, such as the Cognitive Apprenticeship (CA) framework, may be useful to guide preceptor self-assessment and development. However, information is lacking regarding whether the CA framework is consistent with learners' expectations. The purpose of this study was to determine pharmacy learner perspectives on desired preceptor behaviors and qualities and to evaluate their alignment with the CA framework to inform preceptor development. METHODS: Twenty-two learners (nine residents and 13 introductory and advanced pharmacy practice students) participated in nine focus group interviews. Data were analyzed qualitatively by inductive coding and pattern coding and then condensed into themes. After initial analysis, the CA framework was adapted into codes and applied to the data to explore the alignment of quality preceptor characteristics with CA. RESULTS: Learners identified desired general preceptor characteristics, teaching behaviors, and qualities of sites and experience structure in their discussion. All four CA dimensions (Methods, Sociology, Sequencing, and Content) were represented in the described desired preceptor qualities. Most comments were connected to the Methods dimension. CONCLUSIONS: This study supports the use of CA as a framework to guide preceptor development and assessment for desired precepting qualities, preceptor behaviors, and learning environments. Additional research is needed for best practices in implementing CA in preceptor assessment and professional development.

Assessing Cognitive Apprenticeship Impact on Clinical Reasoning in Third-Year Student Pharmacists.

OBJECTIVE: The objective of this study was to evaluate the impact of implementing a cognitive apprenticeship theory (CAT) model into a Doctor of Pharmacy course in improving clinical reasoning skills of third-year student pharmacists over time and preparing them for Advanced Pharmacy Practice Experiences (APPEs). METHODS: This was a single center, nonrandomized, observational before-and-after study from January 2022 through May 2022. Third-year student pharmacists enrolled in the Critical Care Integrated Drugs and Disease pharmacotherapy course at the University of Kentucky College of Pharmacy were administered a well-established and nationally recognized clinical patient case assessment on weeks 1 and 15 of the course. Students were asked to prioritize patient problems and provide recommendations for therapy, goals, and monitoring. Responses were then scored using a predefined case key. In addition, student pharmacists were asked to self-evaluate their confidence in APPE readiness on a 5-point Likert scale. RESULTS: Of the 136 student pharmacists enrolled in the course, 92 (68%) student pharmacists completed both week 1 and week 15 clinical cases and self-assessment surveys, provided informed consent, and were included. Cumulative clinical case scores were significantly increased from week 1 to week 15 (34.8 vs 39.7). In addition, significant improvement was seen in overall problem prioritization, overall recommendations, and self-perceived preparedness for APPE rotations. CONCLUSION: The use of a CAT model into a 15-week pharmacotherapy course improved comprehensive scores of clinical reasoning assessment in third-year student pharmacists and was associated with increased self-perceived confidence and readiness for APPEs.

Reflecting on Students' Experiences of an Innovative Teaching Model During Aged Care Visit in Clinical Placements: A Qualitative Pilot Study.

Purpose: Clinical placement teaching could be challenging due to time constraints, lack of effective teaching models and consensus approaches. Learner-centred approach facilitated deeper learning by demonstrating "seeing-patients-under-supervision" being ideal during Residential-Aged-Care-Facility (RACF)-visit in GP clinical placements. The study aimed to reflect on the students' experiences in aged-care visits by applying an innovative teaching model of "students-being-the-GP-clinician-in-charge-of-RACF-visit-ward-round-under-the-supervision-of-clinical-supervisor". Through students' reflections, this study identified 12 commonly managed RACF problems to be introduced into the curriculum to optimise clinical reasoning learning during RACF-visit. Methods: This qualitative study used online surveys and interviews. All participating students reported all the encountered cases during the RACF visit through an online survey. The participating students acted as GP in charge of all clinical interactions with patients, caregivers, and nurses during RACF visits and final management plan discussions with GP supervisors to ensure clinical-service safety and teaching-and-learning quality. The interview questionnaires applied standard-and-open-ended-questions to examine the impact of this innovative teaching model on clinical-reasoning-learning, clinical-competence-improvement, Objective Structured Clinical Exam (OSCE) preparation, limitations-from-students'-patients'-and-supervisors' perspectives, and intern readiness. Results: An online survey summarising students' encountered cases was returned by 30 students. The 12 most commonly-managed problems were tabulated. Falls, urinary tract infections, and behavioural and psychological symptoms of dementia were the three most commonly-managed problems. All thirty students' reflections indicated the positive impact of the innovative-teaching-models on "Improving-Clinical-Reasoning-Learning", "Enhancing-Clinical-Competency", "Enriching-Salient-Learning-Points", "Facilitating-Feedback-Discussion-with-Supervisor", "Strengthening-OSCE-exam-preparation", "Understanding-the-Limitation-from-students'-patients'-and-supervisors'-perspectives", "Enabling-intern-readiness". Twelve students' individual reflections were demonstrated. Conclusion: This qualitative pilot study demonstrated through students' reflection that "Student-doctor-in-charge-of-nursing-home-round" is an innovative teaching model for clinical reasoning learning. This model extended the concepts of "cognitive-apprenticeship" in the context of modern medical education. Students' reflections and summary of commonly managed problems indicated the need for further study to verify the feasibility of implementing this teaching model in the formal curriculum and creating a RACF-visit-specific curriculum for students.

Fostering Secondary Students' Historical Thinking: A Design Study in Flemish History Education.

A recent curriculum reform in Flanders (Belgium) has introduced historical thinking as a central goal for history education. Historical thinking aims to introduce students to the methods of historians and disciplinary ways of thinking. It is a complex act, requiring the application of substantive and second-order knowledge, and is difficult to foster among students. International (intervention) research has provided several guidelines for the design of instructional practices that are effective in promoting specific aspects of students' historical thinking. However, these studies do not approach historical thinking in a holistic manner, are often vague about how general design principles were adapted to history education, and rarely report on whether the designed curricula were considered relevant and useful by teachers. Taking into account the many difficulties that teachers encounter in designing practices aimed at historical thinking, this design research aims to gain more insight into the design of instructional practices that are both effective in fostering historical thinking in a holistic manner and that are considered socially valid by teachers. The designed artifact is a 12- to 14-h lesson series on the theme "decolonization after 1945," for students in the 12th grade. It applies the model of cognitive apprenticeship's (Collins et al., 1991) general design principles to the specific context of history and approaches historical thinking in a holistic manner. The initial lesson series was evaluated and revised in two rounds based on a pilot study, an expert review and an intervention study.

Describing Ultrasound Skills Teaching by Near-Peer and Faculty Tutors Using Cognitive Apprenticeship.

Phenomenon: Ultrasound skills are becoming increasingly important in clinical practice but are resource-intensive to teach. Near-peer tutors often alleviate faculty teaching burden, but little is known about what teaching methods near-peer and faculty tutors use. Using the lens of cognitive apprenticeship, this study describes how much time faculty and near-peer tutors spend on different teaching methods during abdominal ultrasound skills training. Approach: Sixteen near-peer and 16 faculty tutors were videotaped during one 55-min practical ultrasound lesson with randomly assigned students. Videos were directly coded using Cognitive Apprenticeship teaching methods and activities. Segment durations were summed up and compared quantitatively. Findings: All 32 tutors spent most of the time on observing and helping students (Coaching, Median 29:14 minutes), followed by asking open and stimulating questions (Articulation, 12:04 minutes and demonstrating and giving explanations (Modeling, 04:50 minutes). Overall, distributions of teaching methods used were similar between faculty and near-peer tutors. However, faculty tutors spent more time on helping students manually, whereas near-peer tutors spent more time on exploring students' learning gaps and establishing a safe learning climate. Cognitive Apprenticeship was well suited as observational framework to describe ultrasound skills. Insights: Ultrasound train-the-tutor programs should particularly focus on coaching and articulation. Near-peers' similar use of teaching methods adds to the evidence that supports the use of near-peer teaching in ultrasound skills education.

An innovative approach to using an intensive field course to build scientific and professional skills.

This paper reports on the design and evaluation of Field Studies in Functional Ecology (FSFE), a two-week intensive residential field course that enables students to master core content in functional ecology alongside skills that facilitate their transition from "student" to "scientist." We provide an overview of the course structure, showing how the constituent elements have been designed and refined over successive iterations of the course. We detail how FSFE students: (1) Work closely with discipline specialists to develop a small group project that tests an hypothesis to answer a genuine scientific question in the field; (2) Learn critical skills of data management and communication; and (3) Analyze, interpret, and present their results in the format of a scientific symposium. This process is repeated in an iterative "cognitive apprenticeship" model, supported by a series of workshops that name and explicitly instruct the students in "hard" and "soft" skills (e.g., statistics and teamwork, respectively) critically relevant for research and other careers. FSFE students develop a coherent and nuanced understanding of how to approach and execute ecological studies. The sophisticated knowledge and ecological research skills that they develop during the course is demonstrated through high-quality presentations and peer-reviewed publications in an open-access, student-led journal. We outline our course structure and evaluate its efficacy to show how this novel combination of field course elements allows students to gain maximum value from their educational journey, and to develop cognitive, affective, and reflective tools to help apply their skills as scientists.

Implementing cognitive apprenticeship theory for an ethics module within a first-year pharmacy skills course.

BACKGROUND AND PURPOSE: Critical thinking and problem solving are two skills required to be a successful pharmacist. These skills are often difficult to teach and assess within the classroom. Cognitive apprenticeship theory has been discussed in literature to foster the cognitive and meta-cognitive processes of thinking. Coordinators of a first year Pharmaceutical Skills I course explore how they incorporated this theory into an ethics module to enhance student awareness of thinking and application. EDUCATIONAL ACTIVITY AND SETTING: An ethics module was incorporated into a first year doctor of pharmacy skills course in fall 2021. This module was developed following the four dimensions of cognitive apprenticeship. Lecture materials and ethical debate topics were created by course coordinators and mirrored real time ethical issues surrounding the field of pharmacy. Students were required to use primary literature, the American Pharmacists' Association Code of Ethics, and other ethical terms to support their arguments. Cognitive apprenticeship theory was used throughout the module and post-debate discussions. FINDINGS: The ethics module presented in this course incorporated all dimensions of cognitive apprenticeship. Course coordinators perceived students were able to apply knowledge of ethical principles to scenarios and debates in an effective manner. Purposeful introduction, reiteration, and application offers students the chance to showcase critical thinking and ethical reasoning. SUMMARY: Utilizing the cognitive apprenticeship theory to prepare students for critical thinking is effective when incorporated into a course module. This theory could be successfully implemented into other topics throughout the course and throughout the pharmacy curriculum.

Lessons learned from a formative study evaluating student pharmacists' experience with a case-based learning "choose your own adventure" activity.

BACKGROUND: A case-based learning "Choose Your Own Adventure" (CBL-CYOA) activity was designed to support students in learning to identify drug-related problems and make clinical decisions related to drug therapy management. The purpose of this study was to describe student pharmacists' experiences in order to understand, from their perspective, which design features of the CBL-CYOA activity were valued as useful for developing clinical decision-making skills in an Applied Pharmacy Practice I course. However, several limitations with various features of study design minimized the usefulness of results. IMPACT: In retrospect, methodological limitations with both the survey and focus group designs negatively impacted the interpretation of results in this study. RECOMMENDATIONS: Attention to thoughtful survey development with better alignment to the purpose of the study and neutral questions may produce more useful results. Further, additional focus groups and a purposeful sampling strategy may add to increasing the credibility of the findings in this study. DISCUSSION: Overall, formative studies like this one have the potential to produce insights into how innovative instructional designs operate in real-world contexts. They also have the capacity to output results that provide an evidence base for refining and improving those designs. We hope that our reflections in this paper may be useful to other educators and researchers working to plan similar projects in the future.

Exploring cognitive apprenticeship and teaching practices in pharmacy education.

Health professions schools in the United States and internationally have engaged in curricular changes to better prepare students for the future of health care. However, designing or selecting evidence-based teaching activities can be a challenge. Research suggests the Cognitive Apprenticeship theory is an effective framework for the health professions to inform instruction design, yet these studies have mainly focused on the clinical setting and not the didactic learning environment. This study used qualitative methods to explore the Cognitive Apprenticeship framework in the didactic learning environment and the teaching practices that pharmacy faculty used to explicate their expert thinking to students. Faculty were observed using all four Cognitive Apprenticeship dimensions (ie, Content, Sequencing, Methods, Sociology) in their teaching practice. Patterns were observed in the data revealing complex, short and sometimes spontaneous teaching practices that faculty used to promote learning.

Whether to flip Extreme Apprenticeship: which is more effective in programming instruction?

Programming knowledge is more important than ever in the digital world. However, teaching programming can be challenging, especially with novice learners. Considerable research has been conducted into the most effective methods for teaching programming. Extreme apprenticeship, a variation of cognitive apprenticeship, is a method that has been used in teaching programming at university level in recent years. Because this method focuses particularly on completing lots of exercises with coaching and guidance, it may solve many problems related to learning programming. Flipped learning can be useful for student preparedness and providing sufficient theoretical knowledge at the beginning of the course. This study compares the applications of the extreme apprenticeship method, flipped extreme apprenticeship, and traditional classroom, analyzing them at the university level in terms of their effects on academic achievement and engagement coupled with gender differences. The findings of the study indicate that the extreme apprenticeship and flipped extreme apprenticeship instructional methods improve academic achievement and student engagement in introductory programming more than the traditional method. The results of the research point to important directions for the development of the extreme apprenticeship method in programming instruction and provide a guide for instructors. Supplementary Information: The online version contains supplementary material available at 10.1007/s10639-022-11055-y.

Implementation of the cognitive apprenticeship model for enhancement of advanced searching skills in a pharmacy academia rotation.

BACKGROUND: Pharmacy students are primarily taught literature searching skills didactically during their Doctor of Pharmacy curriculum. To effect change in the area of advanced literature searching skills, a pharmacy librarian joined with two Advanced Pharmacy Practice Experience (APPE) preceptors to design and implement a crash course on applied systematic searching skills for a cohort of four students. CASE PRESENTATION: Through the cognitive apprenticeship model, a Systematic Searching Crash Course (SSCC) was implemented among a cohort of four academic APPE students. Students developed search strategies using controlled vocabulary and free text, translated their searches into multiple databases, and used citation management software to build libraries of evidence. Additionally, the cohort blindly peer reviewed each other's search strategies, wrote literature reviews, and finally conducted a search together without input from the pharmacy librarian. CONCLUSIONS: Review of the pre-/post-course self-assessment taken by the cohort indicates the SSCC is a success in terms of improving student confidence in accessing and synthesizing primary literature. As the crash course is further refined and implemented, there may be more opportunity to embed the course into didactic curriculum and residency programs and to potentially reproduce it for other health science disciplines.

Implementing cognitive apprenticeship theory into the design of a doctor of pharmacy course.

BACKGROUND AND PURPOSE: Cognitive apprenticeship theory is a model instructors can use to develop expert thinking in a classroom setting. Cognitive apprenticeship theory has been discussed in the literature; however, descriptions of its application in the classroom setting are lacking. We describe how cognitive apprenticeship guided the development and implementation of a new critical care course with a goal of making expert thinking "visible" to students. EDUCATIONAL ACTIVITY AND SETTING: A four-credit-hour course implemented in the 2018-2019 academic year was developed around the dimensions of cognitive apprenticeship. Clinical pharmacists with the affiliated healthcare system contributed to the design and implementation. Elements of the course in which cognitive apprenticeship theory guided the design included pre-class work, in-class group work, and an attending-facilitated discussion session. FINDINGS: All four dimensions of cognitive apprenticeship were incorporated throughout the course. The course coordinator perceived that student questions and the quality of the discussion were higher level than in previous years. SUMMARY: Cognitive apprenticeship theory can be used to design and implement a professional doctor of pharmacy course that prepares students for the types of thinking required in practice. We believe this model could be successfully implemented at other schools of pharmacy.

Educational Practice Based on Hypothesis-Driven Physical Examination / 医学教育

During the coronavirus pandemic, we focused on Hypothesis-Driven Physical Examination (HDPE), which is performed while considering physical examination and differential diagnosis as issues that can be learned without directly having contact with patients. We created HDPE scenarios with students who elected general medicine in Clinical Clerkship 2, and we implemented HDPE using that scenario on the last day of the clerkship. The scenario was created online and HDPE was conducted face-to-face. Students could learn correct medical examination techniques and manners through mutual learning. In addition, they could acquire communication and lifelong learning abilities through cooperative learning. We were able to enhance the learning effect through mutual learning that works on the students’ own intrinsic motivation in terms of both creating scenarios for the framework of cognitive apprenticeship and implementing HDPE.

Descriptions and Reflections on the Cognitive Apprenticeship Model of Psychotherapy Training & Supervision.

This paper offers a detailed description of a Cognitive Apprenticeship Model for psychotherapy training and supervision. This form of training has been utilized in a novel psychotherapy training program developed for psychiatric trainees, enrolled in a specialized psychotherapy scholars track, embedded in an adult psychiatric residency training program. The paper offers new elaborations of the model, reflections on the apprenticeship supervision and implementation, and clinical lessons learned. The four dimensions of this model include: (1) acquisition of psychotherapy content knowledge; (2) an application of the Cognitive Apprenticeship Model of Supervision, utilizing modeling, coaching, scaffolding, articulation, reflection and exploration as essential aids in structuring a live, real-time supervisory experience; (3) sequencing of clinical psychotherapy training activities; and (4) use of situated learning and communities of practice, as important components of psychotherapy training. The article also discusses an apprentice method of psychotherapy supervision including the intake, working through, and termination phases, Barriers impeding apprenticeship supervision and implementation, and reflections on participant experiences are discussed. This approach may be valuable to others considering the development or evolution of psychotherapy training programs for psychiatrists, psychologists, social workers, or other mental health professionals.

Piloting a first-year resident-as-teacher workshop to foster evidence-based teaching.

PURPOSE: Residents function as important educators of dental students; however, they often have limited training in educational best-practices. Resident-as-teacher programs have been designed and implemented in other health professions to prepare residents to teach in clinic and classroom settings. In this research, we describe the design, implementation, and evaluation of a 2-day workshop for first-year advanced dental residents. METHODS: The program engaged residents in techniques to: (1) foster psychological safety, (2) use the cognitive apprenticeship framework, (3) deliver quality feedback, and (4) conduct effective didactic instruction. Nineteen first-year residents attended 2 four-hour workshops in July 2019. The impact of the program was evaluated using Kirkpatrick's model, which included participant reactions, learning, and self-reported behaviors. RESULTS: Most residents (at least 83.3%) reported the value and quality of the workshop was high or very high. With regard to knowledge, residents had statistically significant higher scores after the workshop on knowledge questions about cognitive apprenticeship (P < 0.01), feedback strategies (P < 0.05), and classroom instruction techniques (P < 0.05). Resident reported self-efficacy had a statistically significantly increase (P < 0.05) after the workshop in psychological safety, cognitive apprenticeship, and most items related to providing feedback; there were few changes in self-efficacy on classroom instruction strategies. CONCLUSION: Overall, a workshop to prepare residents as teachers can improve knowledge and self-efficacy in evidence-based educational practices.

Psychological safety, the hidden curriculum, and ambiguity in medicine.

Psychological safety is a feeling that individuals are comfortable expressing and being themselves, as well as comfortable sharing concerns and mistakes without fear of embarrassment, shame, ridicule, or retribution. It has long been recognized as part of successful patient safety and quality improvement processes. However, in the realm of medical education, psychological safety is a relatively unknown concept to many educators and learners alike. Learners, whether students or postgraduate trainees, are in a phase of cognitive apprenticeship whereby they learn not only skills and knowledge from teachers as part of an explicit and formal curriculum. At the same time, a hidden curriculum is also part of the learning environment in the form of norms, values, and behaviors exhibited by teachers. These norms, values, and behaviors become part of the culture of the clinical learning environment. The vulnerability of learners in this environment is magnified by the hierarchal nature of medicine, and the complexity, uncertainty, and the ambiguity inherent to medical conditions. This is especially true of cognitive specialties such as rheumatology. Educators who engage in unprofessional behaviors that result in learner humiliation and shame may serve to dampen productive discourse and scientific dialog. Therefore, educators must embrace psychological safety to foster learning and facilitate high-performing teams in the clinical learning environment.Key Points• Psychological safety improves communication and teamwork by allowing individuals to be comfortable expressing and being themselves, as well as comfortable sharing concerns and mistakes without fear of embarrassment, shame, ridicule, or retribution.• Commonly studied in the context of patient safety and quality improvement, psychological safety should extend towards medical education particularly in the context of allowing medical students and postgraduate trainees to be able to voice clinical reasoning in the face of ambiguity.• Educators take on a leadership role when having learners under their supervision; as leaders, educators are the prime movers of psychological safety• Learners in the process of developing their self-identity in the context of their chosen profession adopt not only knowledge and skills within the framework of an explicit and formal curriculum but also norms and values from daily behavior and language educators present in the clinical learning environment of learners; these norms and values are collectively part of the hidden curriculum.

The Fracture Liaison Service to close the osteoporosis care gap: a leadership educational model for undergraduate and postgraduate trainees.

Osteoporotic fractures have been rising and are a cause of severe morbidity and mortality. Care gaps exist in osteoporosis treatment and diagnosis, which presents an opportunity for education. A number of healthcare systems in the world have developed a fracture liaison service (FLS) to combat osteoporotic fractures. The Rheumatology division at Loma Linda University Health (LLUH) developed an FLS not only to address osteoporosis care gaps but to also develop a new educational model. An interdisciplinary model of osteoporosis care has been implemented along with a revamp of educational focus on osteoporosis and bone health in the rheumatology fellowship and internal medicine residency. Pre-LLUH FLS studies showed that 85% of patients pre-fracture were never screened nor treated for osteoporosis; post-fracture, only 10% of patients were treated, and only 6% had dual x-ray absorptiometry (DXA). Notably, 30% had a prior fracture. We discuss how the FLS has served as a catalyst for education, not only at our academic center but also as an outreach for our community in order to elevate the care of osteoporosis in our community.Key Points• Care gaps exist in osteoporosis treatment and are addressed by the Fracture Liaison Service.• The Loma Linda University Health Fracture Liaison Service is an interdisciplinary program.• The Fracture Liaison Service is an educational model that gives hands on learning through an amalgam of processes, namely quality improvement through the Plan-Do-Study-Act cycle and medical education through Kolb's learning cycle and cognitive apprenticeship.