Medical competence as a multilayered construct.

BACKGROUND: The conceptualisation of medical competence is central to its use in competency-based medical education. Calls for 'fixed standards' with 'flexible pathways', recommended in recent reports, require competence to be well defined. Making competence explicit and measurable has, however, been difficult, in part due to a tension between the need for standardisation and the acknowledgment that medical professionals must also be valued as unique individuals. To address these conflicting demands, a multilayered conceptualisation of competence is proposed, with implications for the definition of standards and approaches to assessment. THE MODEL: Three layers are elaborated. This first is a core layer of canonical knowledge and skill, 'that, which every professional should possess', independent of the context of practice. The second layer is context-dependent knowledge, skill, and attitude, visible through practice in health care. The third layer of personalised competence includes personal skills, interests, habits and convictions, integrated with one's personality. This layer, discussed with reference to Vygotsky's concept of Perezhivanie, cognitive load theory, self-determination theory and Maslow's 'self-actualisation', may be regarded as the art of medicine. We propose that fully matured professional competence requires all three layers, but that the assessment of each layer is different. IMPLICATIONS: The assessment of canonical knowledge and skills (Layer 1) can be approached with classical psychometric conditions, that is, similar tests, circumstances and criteria for all. Context-dependent medical competence (Layer 2) must be assessed differently, because conditions of assessment across candidates cannot be standardised. Here, multiple sources of information must be merged and intersubjective expert agreement should ground decisions about progression and level of clinical autonomy of trainees. Competence as the art of medicine (Layer 3) cannot be standardised and should not be assessed with the purpose of permission to practice. The pursuit of personal excellence in this level, however, can be recognised and rewarded.

Group concept mapping for health professions education scholarship.

While explicit conceptual models help to inform research, they are left out of much of the health professions education (HPE) literature. One reason may be the limited understanding about how to develop conceptual models with intention and rigor. Group concept mapping (GCM) is a mixed methods conceptualization approach that has been used to develop frameworks for planning and evaluation, but GCM has not been common in HPE. The purpose of this article is to describe GCM in order to make it more accessible for HPE scholars. We recount the origins and evolution of GCM and summarize its core features: GCM can combine multiple stakeholder perspectives in a systematic and inclusive manner to generate explicit conceptual models. Based on the literature and prior experience using GCM, we detail seven steps in GCM: (1) brainstorming ideas to a specific "focus prompt," (2) preparing ideas by removing duplicates and editing for consistency, (3) sorting ideas according to conceptual similarity, (4) generating the point map through quantitative analysis, (5) interpreting cluster map options, (6) summarizing the final concept map, and (7) reporting and using the map. We provide illustrative examples from HPE studies and compare GCM to other conceptualization methods. GCM has great potential to add to the myriad of methodologies open to HPE researchers. Its alignment with principles of diversity and inclusivity, as well as the need to be systematic in applying theoretical and conceptual frameworks to practice, make it a method well suited for the complexities of contemporary HPE scholarship.

Seeing with greater clarity: Stakeholder ratings of blind spots in U.S. medical education.

BACKGROUND: Although medical education is affected by numerous blind spots, there is limited evidence to determine which blind spots to prioritize. METHODS: In summer 2022, we surveyed stakeholders from U.S. medical education who had identified 9 domains and 72 subdomains of blind spots. Respondents used 4-point Likert-type scales to rate the extent and magnitude of problems caused for each domain and subdomain. Respondents also provided comments for which we did content analysis. RESULTS: A total of 23/27 (85%) stakeholders responded. The majority of respondents rated each blind spot domain as moderate-major in both extent and problems they cause. Patient perspectives and voices that are not heard, valued, or understood was the domain with the most stakeholders rating extent (n = 20, 87%) and problems caused (n = 23, 100%) as moderate or major. Admitting and selecting learners likely to practice in settings of highest need was the subdomain with the most stakeholders rating extent (n = 21, 91%) and problems caused (n = 22, 96%) as moderate or major. Respondents' comments suggested blind spots may depend on context and persist because of hierarchies and tradition. DISCUSSION: We found blind spots differed in relative importance. These data may inform further research and direct interventions to improve medical education.

Blind spots in medical education - International perspectives.

BACKGROUND: All individuals and groups have blind spots that can create problems if unaddressed. The goal of this study was to examine blind spots in medical education from international perspectives. METHODS: From December 2022 to March 2023, we distributed an electronic survey through international networks of medical students, postgraduate trainees, and medical educators. Respondents named blind spots affecting their medical education system and then rated nine blind spot domains from a study of U.S. medical education along five-point Likert-type scales (1 = much less attention needed; 5 = much more attention needed). We tested for differences between blind spot ratings by respondent groups. We also analyzed the blind spots that respondents identified to determine those not previously described and performed content analysis on open-ended responses about blind spot domains. RESULTS: There were 356 respondents from 88 countries, including 127 (44%) educators, 80 (28%) medical students, and 33 (11%) postgraduate trainees. At least 80% of respondents rated each blind spot domain as needing 'more' or 'much more' attention; the highest was 88% for 'Patient perspectives and voices that are not heard, valued, or understood.' In analyses by gender, role in medical education, World Bank country income level, and region, a mean difference of 0.5 was seen in only five of the possible 279 statistical comparisons. Of 885 blind spots documented, new blind spot areas related to issues that crossed national boundaries (e.g. international standards) and the sufficiency of resources to support medical education. Comments about the nine blind spot domains illustrated that cultural, health system, and governmental elements influenced how blind spots are manifested across different settings. DISCUSSION: There may be general agreement throughout the world about blind spots in medical education that deserve more attention. This could establish a basis for coordinated international effort to allocate resources and tailor interventions that advance medical education.

Interventions for undergraduate and postgraduate medical learners with academic difficulties: A BEME systematic review update: BEME Guide No. 85.

BACKGROUND: Clinical teachers often struggle to record trainee underperformance due to lacking evidence-based remediation options. OBJECTIVES: To provide updated evidence-based recommendations for addressing academic difficulties among undergraduate and postgraduate medical learners. METHODS: A systematic review searched databases including MEDLINE, CINAHL, EMBASE, ERIC, Education Source, and PsycINFO (2016-2021), replicating the original Best Evidence Medical Education 56 review strategy. Original research/innovation reports describing intervention(s) for medical learners with academic difficulties were included. Data extraction used Michie's Behaviour Change Techniques (BCT) Taxonomy and program evaluation models from Stufflebeam and Kirkpatrick. Quality appraised used the Mixed Methods Appraisal Tool (MMAT). Authors synthesized extracted evidence by adapting GRADE approach to formulate recommendations. RESULTS: Eighteen articles met the inclusion criteria, primarily addressing knowledge (66.7%), skills (66.7%), attitudinal problems (50%) and learner's personal challenges (27.8%). Feedback and monitoring was the most frequently employed BCT. Study quality varied (MMAT 0-100%). We identified nineteen interventions (UG: n = 9, PG: n = 12), introducing twelve new thematic content. Newly thematic content addressed contemporary learning challenges such as academic procrastination, and use of technology-enhanced learning resources. Combined with previous interventions, the review offers a total dataset of 121 interventions. CONCLUSION: This review offers additional evidence-based interventions for learners with academic difficulties, supporting teaching, learning, faculty development, and research efforts.

Deconstructing the professional identity formation of basic science teachers in medical education.

PURPOSE: The role of basic science teachers (BSTs) in medical education has been changing dynamically. Less is known, however, about how BSTs perceive their professional identity and what factors influence its formation. This study aims to explore how the professional identity of BSTs is formed and what factors influence this professional identity formation (PIF) using the 4S ("Situation, Self, Support, Strategies") Schlossberg framework. METHOD: A qualitative descriptive study using focus groups (FGs) was conducted. Maximum variation sampling was used to purposively select BSTs. A rigorous thematic analysis was completed, including independent thematic analysis, intermittent checking and iterative discussions among researchers, and member checking. RESULTS: Nine FGs, involving 60 teachers, were conducted. The findings highlighted four major themes reflecting the 4S framework: the self as internal driver, early-career events and opportunities, individual and institutional support, and active participation in continuing professional development. Both the "Self" and the "Situation" components prompted the BSTs to utilize supports and enact strategies to become professional teachers. Although the BSTs in this study were primarily internally driven, they relied more on existing support systems rather than engaging in various strategies to support their growth. CONCLUSION: It is important to address the PIF of BSTs given their dynamic roles. Looking through the lens of the 4S framework, PIF is indeed a transition process. A structured, stepwise faculty development program, including mentorship, reflective practice, and a community of practice designed to foster BSTs' identities, should be created, taking into consideration the diverse factors influencing the PIF of BSTs.

Linking leadership development programs for physicians with organization-level outcomes: a realist review.

BACKGROUND: Hospitals invest in Leadership Development Programs (LDPs) for physicians, assuming they benefit the organization's performance. Researchers have listed the advantages of LDPs, but knowledge of how and why organization-level outcomes are achieved is missing. OBJECTIVE: To investigate how, why and under which circumstances LDPs for physicians can impact organization-level outcomes. METHODS: We conducted a realist review, following the RAMESES guidelines. Scientific articles and grey literature published between January 2010 and March 2021 evaluating a leadership intervention for physicians in the hospital setting were considered for inclusion. The following databases were searched: Medline, PsycInfo, ERIC, Web of Science, and Academic Search Premier. Based on the included documents, we developed a LDP middle-range program theory (MRPT) consisting of Context-Mechanism-Outcome configurations (CMOs) describing how specific contexts (C) trigger certain mechanisms (M) to generate organization-level outcomes (O). RESULTS: In total, 3904 titles and abstracts and, subsequently, 100 full-text documents were inspected; 38 documents with LDPs from multiple countries informed our MRPT. The MRPT includes five CMOs that describe how LDPs can impact the organization-level outcomes categories 'culture', 'quality improvement', and 'the leadership pipeline': 'Acquiring self-insight and people skills (CMO1)', 'Intentionally building professional networks (CMO2)', 'Supporting quality improvement projects (CMO3)', 'Tailored LDP content prepares physicians (CMO4)', and 'Valuing physician leaders and organizational commitment (CMO5)'. Culture was the outcome of CMO1 and CMO2, quality improvement of CMO2 and CMO3, and the leadership pipeline of CMO2, CMO4, and CMO5. These CMOs operated within an overarching context, the leadership ecosystem, that determined realizing and sustaining organization-level outcomes. CONCLUSIONS: LDPs benefit organization-level outcomes through multiple mechanisms. Creating the contexts to trigger these mechanisms depends on the resources invested in LDPs and adequately supporting physicians. LDP providers can use the presented MRPT to guide the development of LDPs when aiming for specific organization-level outcomes.

Using Group Concept Mapping to Explore Medical Education's Blind Spots.

PHENOMENON: All individuals and groups have blind spots that can lead to mistakes, perpetuate biases, and limit innovations. The goal of this study was to better understand how blind spots manifest in medical education by seeking them out in the U.S. APPROACH: We conducted group concept mapping (GCM), a research method that involves brainstorming ideas, sorting them according to conceptual similarity, generating a point map that represents consensus among sorters, and interpreting the cluster maps to arrive at a final concept map. Participants in this study were stakeholders from the U.S. medical education system (i.e., learners, educators, administrators, regulators, researchers, and commercial resource producers) and those from the broader U.S. health system (i.e., patients, nurses, public health professionals, and health system administrators). All participants brainstormed ideas to the focus prompt: "To educate physicians who can meet the health needs of patients in the U.S. health system, medical education should become less blind to (or pay more attention to) …" Responses to this prompt were reviewed and synthesized by our study team to prepare them for sorting, which was done by a subset of participants from the medical education system. GCM software combined sorting solutions using a multidimensional scaling analysis to produce a point map and performed cluster analyses to generate cluster solution options. Our study team reviewed and interpreted all cluster solutions from five to 25 clusters to decide upon the final concept map. FINDINGS: Twenty-seven stakeholders shared 298 blind spots during brainstorming. To decrease redundancy, we reduced these to 208 in preparation for sorting. Ten stakeholders independently sorted the blind spots, and the final concept map included 9 domains and 72 subdomains of blind spots that related to (1) admissions processes; (2) teaching practices; (3) assessment and curricular designs; (4) inequities in education and health; (5) professional growth and identity formation; (6) patient perspectives; (7) teamwork and leadership; (8) health systems care models and financial practices; and (9) government and business policies. INSIGHTS: Soliciting perspectives from diverse stakeholders to identify blind spots in medical education uncovered a wide array of issues that deserve more attention. The concept map may also be used to help prioritize resources and direct interventions that can stimulate change and bring medical education into better alignment with the health needs of patients and communities.

"What kind of doctor do you want to become?": Clinical supervisors' perceptions of their roles in the professional identity formation of General Practice residents.

PURPOSE: Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in residency, and little is known about supervisors' perceptions of their roles in residents' PIF. In this study, we sought to understand how supervisors perceive their roles in the PIF of General Practice (GP) residents. MATERIALS AND METHODS: Guided by principles of qualitative description, we conducted eight focus groups with 55 supervisors at four General Practice training institutes across the Netherlands. Informed by a conceptual framework of PIF, we performed a thematic analysis of focus group transcripts. RESULTS: Three themes related to how GP supervisors described their roles in supporting residents' PIF: supervising with the desired goal of GP training in mind; role modeling and mentoring as key strategies to achieve that goal; and the value of developing bonds of trust to support the process. CONCLUSIONS: To our knowledge, this study is the first to explore PIF in GP training from the perspective of clinical supervisors. The identified themes mirror the components of the therapeutic alliance between doctors and patients from a supervisor's perspective and highlight the pivotal roles of the supervisor in a resident's PIF.

Twelve tips for small group teaching 2.0 - Rebooted for remote and HyFlex learning.

Small group teaching (SGT) is not just the delivery of teaching to a small number of learners - it is, instead, underpinned by learner-learner interaction, discussion, and collaboration. The advent of readily available technology, combined with the need to maintain learner and teacher safety during the COVID-19 pandemic, has led to a surge in remote learning, and significant increases in synchronous hybrid learning environments, also known as HyFlex learning, in which some learners join remotely and others do so in-person. Teaching in this manner brings new challenges and opportunities and, when compared to face-to-face SGT, requires teachers to employ a complementary repertoire of skills. Against this backdrop, and with the pressing need to up-skill teachers in this domain, we take a fresh look at previously published tips for SGT and reboot these strategies in the context of remote and HyFlex SGT. The challenges of adapting these tips in a changed environment will be considered, and refashioned strategies for their application will be offered.

How learning-centred beliefs relate to awareness of educational identity and mission: An exploratory study among medical educators.

INTRODUCTION: Although learning-centred education would be most effective if all medical educators held learning-centred beliefs, many educators still hold teaching-centred beliefs. A previously developed theoretical model describes a relationship between beliefs, educational identity and 'mission,' meaning that which inspires and drives educators. To increase our understanding of why educators hold certain beliefs, we explored the empirical relationship between educators' beliefs and their awareness of their educational identity and mission. METHODS: A qualitative study was conducted using in-depth interviews with medical educators. We performed a deductive thematic analysis employing two existing models to examine educators' beliefs about teaching and learning and their awareness of their educational identity and mission. RESULTS: Educators demonstrated both teaching-centred and learning-centred beliefs, which aligned with an awareness of their educational identity and mission. While educators who were unaware of both their identity and mission displayed teaching-centred beliefs, educators aware of their identity and mission displayed learning-centred beliefs. Those who were aware of their identity, but not their mission, displayed either teaching- or learning-centredness. CONCLUSIONS: Medical educators' awareness of identity and mission are related to their beliefs about education. Further research is needed into whether beliefs can change over time by increasing identity and mission awareness.

Professional identity formation of medical teachers in a non-Western setting.

INTRODUCTION: Understanding and supporting professional identity formation (PIF) among medical teachers has become increasingly important in faculty development programs. In this study, we explored medical teachers' PIF in Indonesia. METHODS: We conducted a qualitative descriptive study using focus group discussions (FGDs) at four medical schools in Indonesia. Basic science and clinical teachers from four different schools were selected to participate. Data were transcribed, coded, and analysed to develop themes and subthemes. RESULTS: Seventeen FGDs were completed, involving 60 basic science and 59 clinical teachers. Four major themes regarding the formation of medical teachers' professional identity emerged: an internal dialogue between intrinsic values and external influences, empowerment through early socialization, experiential workplace learning, and envisioning the future. The PIF process was similar for basic science and clinical teachers. CONCLUSION: Our findings suggested that PIF among medical teachers in a non-Western setting is a continuous and dynamic process that is shaped by key socialization factors (e.g. role models, workplace learning, peer support), with significant influences from religious beliefs, family values, and societal recognition. Faculty development programs should consider the dynamic and continuous nature of PIF among medical teachers and encourage clinicians and basic scientists to explore their values and beliefs, realize their goals, and envision their future.

Beyond the cultural myth of medical meritocracy.

BACKGROUND: We examine the cultural myth of the medical meritocracy, whereby the "best and the brightest" are admitted and promoted within the profession. We explore how this narrative guides medical practice in ways that may no longer be adequate in the contexts of practice today. METHODS: Narrative analysis of medical students' and physicians' stories. RESULTS: Hierarchies of privilege within medicine are linked to meritocracy and the trope of the "hero's story" in literature. Gender and other forms of difference are generally excluded from narratives of excellence, which suggests operative mechanisms that may be contributory to observed differences in attainment. We discuss how the notion of diversity is formulated in medicine as a "problem" to be accommodated within merit, and posit that medical practice today requires a reformulation of the notion of merit in medicine, valorising a diversity of life experience and skills, rather than "retrofitting" diversity concerns as problems to be accommodated within current constructs of merit. CONCLUSIONS: Three main action-oriented outcomes for a better formulation of merit relevant to medical practice today are suggested: (a) development of assessors' critical consciousness regarding the structural issues in merit assignment; (b) alignment of merit criteria with relevant societal outcomes, and (c) developing inclusive leadership to accommodate the greater diversity of excellence needed in today's context of medical practice. A reformulation of the stories through which medical practitioners and educators communicate and validate aspects of medical practice will be required in order for the profession to continue to have relevance to the diverse societies it serves.

Faculty development: From rubies to oak.

Introduction: Faculty development has played a significant role in health professions education over the last 40 years. The goal of this perspective is to present a portrait of faculty development in Medical Teacher since its inception and to highlight emerging trends moving forward.Method: All issues of Medical Teacher were reviewed, using the search terms faculty development, staff development, professional development, or in-service training for faculty. The search yielded 286 results of which 145 focused specifically on faculty development initiatives, reviews, or frameworks.Findings: This review demonstrated a significant growth in publications related to faculty development in Medical Teacher over the last 40 years, with a primary focus on teaching improvement and traditional approaches to faculty development, including workshops, short courses and other structured, group activities. The international nature of faculty development was also highlighted.Recommendations: Moving forward, it is suggested that we: broaden the scope of faculty development from teaching to academic development; expand our approaches to faculty development, to include peer coaching, workplace learning and communities of practice; utilize a competency-based framework to guide the development of faculty development curricula; support teachers' professional identities through faculty development; focus on organizational development and change; and rigorously promote research and scholarship in faculty development.

Twelve tips for implementing a community of practice for faculty development.

Teaching and learning practices often fail to incorporate new concepts in the ever-evolving field of medical education. Although medical education research provides new insights into curricular development, learners' engagement, assessment methods, professional development, interprofessional education, and so forth, faculty members often struggle to modernize their teaching practices. Communities of practice (CoP) for faculty development offer an effective and sustainable approach for knowledge management and implementation of best practices. A successful CoP creates and shares knowledge in the context of a specific practice toward the development of expertise. CoPs' collaborative nature, based on the co-creation of practical solutions to daily problems, aligns well with the goals of applying best practices in health professions education and training new faculty members. In our article, we share 12 tips for implementing a community of practice for faculty development. The tips were based on a comprehensive literature review and the authors' experiences.

The use of BEME reviews in the medical education literature.

INTRODUCTION: Knowledge syntheses in medical education are intended to promote the translation to, and mobilization of, research knowledge into practice. Despite the effort invested in conducting them, how these knowledge syntheses are used is unclear. This study aimed to explore how knowledge syntheses published by the Best Evidence Medical Education Collaboration (BEME) have been used in a cross-section of published literature. METHODS: Citation patterns for BEME reviews were explored using data drawn from Web of Science and Scopus, and a sub-sample of citing papers. RESULTS: Bibliometric data on 3419 papers citing 29 BEME reviews were analysed. More detailed data were extracted from a random sample of 629 full-text papers. DISCUSSION: BEME reviews were most often positioned to consolidate and summarize the current state of knowledge on a particular topic and to identify gaps in the literature; they were also used to justify current research, and less frequently to contextualize and explain results, or direct future areas of research. Their use to identify instruments or methodological approaches was relatively absent. CONCLUSION: While BEME reviews are primarily used to justify and support other studies, the current literature does not demonstrate their translation to educational practice.

Managing the tension: From innovation to application in health professions education.

Innovations in education are essential for solving problems and introducing new ways of thinking. However, implementation of these innovations must take several factors into consideration, including the context, the environment, the stakeholders, the technology needed, the cost, the pace of implementation, appropriateness, and available resources. When these factors are not balanced and considered, tensions arise. This paper describes tensions in five major educational domains, namely curriculum, instruction, assessment, accreditation/regulation, and faculty development. For each of these domains, the typical problems are described, and solutions are presented to manage the tension.

Supporting the development of a professional identity: General principles.

While teaching medical professionalism has been an important aspect of medical education over the past two decades, the recent emergence of professional identity formation as an important concept has led to a reexamination of how best to ensure that medical graduates come to "think, act, and feel like a physician." If the recommendation that professional identity formation as an educational objective becomes a reality, curricular change to support this objective is required and the principles that guided programs designed to teach professionalism must be reexamined. It is proposed that the social learning theory communities of practice serve as the theoretical basis of the curricular revision as the theory is strongly linked to identity formation. Curricular changes that support professional identity formation include: the necessity to establish identity formation as an educational objective, include a cognitive base on the subject in the formal curriculum, to engage students in the development of their own identities, provide a welcoming community that facilitates their entry, and offer faculty development to ensure that all understand the educational objective and the means chosen to achieve it. Finally, there is a need to assist students as they chart progress towards becoming a professional.

Use of evidence in health professions education: Attitudes, practices, barriers and supports.

Introduction: Health professions educators are increasingly called upon to apply an evidence-informed approach to teaching and assessment practices. There is scant empirical research exploring educators' attitudes, practices, and perceived barriers and supports to using research evidence in educational practice. Methods: We conducted a survey of AMEE members to explore three domains related to evidence-informed health professions education: (1) attitudes; (2) practices; and (3) supports and barriers. Analyses involved descriptive statistics to characterize participants' responses per domain, exploratory factor analysis, and multivariate regression analyses. Results: Three hundred ninety-six (∼10%) participants representing health professions educators (HPEs) and non HPEs (e.g. PhDs) and different roles (e.g. teacher, administrator) completed the survey. Attitudes toward evidence-informed HPE were generally favorable. Several barriers preclude participants from engaging in evidence-informed approaches to health professions education (HPE). Discussion: This study provides preliminary evidence on the attitudes toward and perceived barriers and supports of research use in HPE from different groups of HP educators, clinicians, and administrators. The findings for each of the three domains require additional exploration using qualitative methodologies. Conclusion: Targeted interventions designed to increase the uptake of research in HPE should consider different stakeholder groups' perceptions regarding these approaches, current vs. best practices, and factors that may impede evidence-informed approaches.