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

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

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

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

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

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

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

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

Assessing undergraduate medical education through a generalist lens.

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

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

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

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

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

Productive failure as an instructional approach to promote future learning.

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

Back from basics: integration of science and practice in medical education.

CONTEXT: In 1988, the Edinburgh Declaration challenged medical teachers, curriculum designers and leaders to make an organised effort to change medical education for the better. Among a series of recommendations was a call to integrate training in science and clinical practice across a breadth of clinical contexts. The aim was to create physicians who could serve the needs of all people and provide care in a multitude of contexts. In the years since, in the numerous efforts towards integration, new models of curricula have been proposed and implemented with varying levels of success. SCOPE OF REVIEW: In this paper, we examine the evolution of curricular integration since the Edinburgh Declaration, and discuss theoretical advances and practical solutions. In doing so, we draw on recent consensus reports on the state of medical education, emblematic initiatives reported in the literature, and developments in education theory pertinent to the role of integrated curricula. CONCLUSIONS: Interest in integration persists despite 30 years of efforts to respond to the Edinburgh Declaration. We argue, however, that a critical shift has taken place with respect to the conception of integration, whereby empirical models support a view of integration as pertaining to both cognitive activity and curricular structure. In addition, we describe a broader definition of 'basic science' relevant to clinical practice that encompasses social and behavioural sciences, as well as knowledge derived from biomedical science.

Knowing How and Knowing Why: testing the effect of instruction designed for cognitive integration on procedural skills transfer.

Transfer is a desired outcome of simulation-based training, yet evidence for how instructional design features promote transfer is lacking. In clinical reasoning, transfer is improved when trainees experience instruction integrating basic science explanations with clinical signs and symptoms. To test whether integrated instruction has similar effects in procedural skills (i.e., psychomotor skills) training, we studied the impact of instruction that integrates conceptual (why) and procedural (how) knowledge on the retention and transfer of simulation-based lumbar puncture (LP) skill. Medical students (N = 30) were randomized into two groups that accessed different instructional videos during a 60-min self-regulated training session. An unintegrated video provided procedural How instruction via step-by-step demonstrations of LP, and an integrated video provided the same How instruction with integrated conceptual Why explanations (e.g., anatomy) for key steps. Two blinded raters scored post-test, retention, and transfer performances using a global rating scale. Participants also completed written procedural and conceptual knowledge tests. We used simple mediation regression analyses to assess the total and indirect effects (mediated by conceptual knowledge) of integrated instruction on retention and transfer. Integrated instruction was associated with improved conceptual (p < .001) but not procedural knowledge test scores (p = .11). We found no total effect of group (p > .05). We did find a positive indirect group effect on skill retention (B ab  = .93, p < .05) and transfer (B ab  = .59, p < .05), mediated through participants improved conceptual knowledge. Integrated instruction may improve trainees' skill retention and transfer through gains in conceptual knowledge. Such integrated instruction may be an instructional design feature for simulation-based training aimed at improving transfer outcomes.

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

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

Examining the effect of self-explanation on cognitive integration of basic and clinical sciences in novices.

Several studies have shown that cognitive integration of basic and clinical sciences supports diagnostic reasoning in novices; however, there has been limited exploration of the ways in which educators can translate this model of mental activity into sound instructional strategies. The use of self-explanation during learning has the potential to promote and support the development of integrated knowledge by encouraging novices to elaborate on the causal relationship between clinical features and basic science mechanisms. To explore the effect of this strategy, we compared diagnostic efficacy of teaching students (n = 71) the clinical features of four musculoskeletal pathologies using either (1) integrated causal basic science descriptions (BaSci group); (2) integrated causal basic science descriptions combined with self-explanation prompts (SE group); (3) basic science mechanisms segregated from the clinical features (SG group). All participants completed a diagnostic accuracy test immediately after learning and 1-week later. The results showed that the BaSci group performed significantly better compared to the SE (p = 0.019) and SG groups (p = 0.004); however, no difference was observed between the SE and SG groups (p = 0.91). We hypothesize that the structure of the self-explanation task may not have supported the development of a holistic conceptual understanding of each disease. These findings suggest that integration strategies need to be carefully structured and applied in ways that support the holistic story created by integrated basic science instruction in order to foster conceptual coherence and to capitalize on the benefits of cognition integration.

Preparation for future learning: a missing competency in health professions education?

CONTEXT: Evidence suggests that clinicians may not be learning effectively from all facets of their practice, potentially because their training has not fully prepared them to do so. To address this gap, we argue that there is a need to identify systems of instruction and assessment that enhance clinicians' 'preparation for future learning'. Preparation for future learning (PFL) is understood to be the capacity to learn new information, to use resources effectively and innovatively, and to invent new strategies for learning and problem solving in practice. CURRENT STATE: Education researchers have developed study designs that use dynamic assessments to measure what trainees have acquired in the past, as well as what they are able to learn in the present. More recently, researchers have also started to emphasise and measure whether and how trainees take action to gain the information they need to learn. Knowing that there are study designs and emerging metrics for assessing PFL, the next question is how to design instruction that helps trainees develop PFL capacities. Although research evidence is still accumulating, the current evidence base suggests training that encourages 'productive failure' through guided discovery learning (i.e. where trainees solve problems and perform tasks without direct instruction, though often with some form of feedback) creates challenging conditions that enhance learning and equip trainees with PFL-related behaviours. CONCLUSIONS: Preparation for future learning and the associated capacity of being adaptive as one learns in and from training and clinical practice have been missed in most contemporary training and assessment systems. We propose a research agenda that (i) explores how real-world adaptive expert activity unfolds in the health care workplace to inform the design of instruction for developing PFL, (ii) identifies measures of behaviours that relate to PFL, and (iii) addresses potential sociocultural barriers that limit clinicians' opportunities to learn from their daily practice.

Test-enhanced learning and its effect on comprehension and diagnostic accuracy.

CONTEXT: In health professions education, tests have traditionally been used to assess the skills and knowledge of learners. More recently, research in psychology and education has shown that tests can also be used to enhance student memory; a phenomenon called the 'testing effect'. Much of the research in this domain has focused on enhancing rote memory of simple facts, and not on the deeper comprehension and application of complex theoretical knowledge necessary to diagnose and manage patients. The purpose of this study was to examine the effects of testing on students' comprehension of the basic science mechanisms and diagnostic accuracy. METHODS: Undergraduate dental and dental hygiene students (n = 112) were taught the radiographic features and pathophysiology underlying four intrabony abnormalities. Participants were divided into two groups: the test-enhanced (TE) condition and the study (ST) condition. Following the learning phase, the TE condition group completed an interventional test that tested the basic science mechanisms and the ST condition group was given additional study passages without being tested. Participants in both groups then completed a diagnostic test and a memory test immediately after the learning phase and 1 week later. RESULTS: A main effect of testing condition was found. The participants in the TE condition group outperformed those in the ST condition group on immediate and delayed testing. Unlike the diagnostic test, the memory test showed no difference between the groups. CONCLUSION: The inclusion of the basic science test appears to have improved the students' understanding of the underlying disease mechanisms learned and also improved their performance on a test of diagnostic accuracy.

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

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

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

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