Team Stress and Its Impact on Interprofessional Teams: A Narrative Review.

Phenomenon: Interprofessional healthcare team (IHT) collaboration can produce powerful clinical benefits for patients; however, these benefits are difficult to harness when IHTs work in stressful contexts. Research about stress in healthcare typically examines stress as an individual psychological phenomenon, but stress is not only a person-centered experience. Team stress also affects the team's performance. Unfortunately, research into team stress is limited and scattered across many disciplines. We cannot prepare future healthcare professionals to work as part of IHTs in high-stress environments (e.g., emergency medicine, disaster response) unless we review how this dispersed literature is relevant to medical education. Approach: The authors conducted a narrative review of the literature on team stress experienced by interprofessional teams. The team searched five databases between 1 Jan 1990 and 16 August 2021 using the search terms: teams AND stress AND performance. Guided by four research questions, the authors reviewed and abstracted data from the 22 relevant manuscripts. Findings: Challenging problems, time pressure, life threats, environmental distractors, and communication issues are the stressors that the literature reports that teams faced. Teams reacted to team stress with engagement/cohesion and communication/coordination. Stressors impact team stress by either hindering or improving team performance. Critical thinking/decision-making, team behaviors, and time for task completion were the areas of performance affected by team stress. High-quality communication, non-technical skills training, and shared mental models were identified as performance safeguards for teams experiencing team stress. Insights: The review findings adjust current models explaining drivers of efficient and effective teams within the context of interprofessional teams. By understanding how team stress impacts teams, we can better prepare healthcare professionals to work in IHTs to meet the demands placed on them by the ever-increasing rate of high-stress medical situations.

Professional identity struggle and ideology: A qualitative study of residents' experiences.

INTRODUCTION: To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. METHODS: We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. RESULTS: We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. CONCLUSION: This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

"A whole other competence story": exploring faculty perspectives on the process of workplace-based assessment of entrustable professional activities.

The centrality of entrustable professional activities (EPAs) in competency-based medical education (CBME) is predicated on the assumption that low-stakes, high-frequency workplace-based assessments used in a programmatic approach will result in accurate and defensible judgments of competence. While there have been conversations in the literature regarding the potential of this approach, only recently has the conversation begun to explore the actual experiences of clinical faculty in this process. The purpose of this qualitative study was to explore the process of EPA assessment for faculty in everyday practice. We conducted 18 semi-structured interviews with Anesthesia faculty at a Canadian academic center. Participants were asked to describe how they engage in EPA assessment in daily practice and the factors they considered. Interviews were audio-recorded, transcribed, and analysed using the constant comparative method of grounded theory. Participants in this study perceived two sources of tension in the EPA assessment process that influenced their scoring on official forms: the potential constraints of the assessment forms and the potential consequences of their assessment outcome. This was particularly salient in circumstances of uncertainty regarding the learner's level of competence. Ultimately, EPA assessment in CBME may be experienced as higher-stakes by faculty than officially recognized due to these tensions, suggesting a layer of discomfort and burden in the process that may potentially interfere with the goal of assessment for learning. Acknowledging and understanding the nature of this burden and identifying strategies to mitigate it are critical to achieving the assessment goals of CBME.

Expanding the advocacy lens: using photo-elicitation to capture patients' and physicians' perspectives about health advocacy.

Heath advocacy (HA) remains a difficult competency to train and assess, in part because practicing physicians and learners carry uncertainty about what HA means and we are missing patients' perspectives about the role HA plays in their care. Visual methods are useful tools for exploring nebulous topics in health professions education; using these participatory approaches with physicians and patients might counteract the identified training challenges around HA and more importantly, remedy the exclusion of patient perspectives. In this paper we share the verbal and visual reflections of patients and physicians regarding their conceptualizations of, and engagement in 'everyday' advocacy. In doing so, we reveal some of HA's hidden dimensions and what their images uncovered about the role of advocacy in patient care. Constructivist grounded theory guided data collection and analysis. Data was collected through semi-structured interviews and photo-elicitation, a visual research method that uses participant generated photographs to elicit participants knowledge and experiences around a particular topic. We invited patients living with chronic health conditions (n = 10) and physicians from diverse medical and surgical specialties (n = 14) to self-select photographs representing their experiences navigating HA in their personal and professional lives. Both groups found taking photographs useful for revealing the nuanced and circumstantial factors that either enabled or challenged their engagement in HA. While patients' photos highlighted their embodiment of HA, physicians' photos depicted HA as something quite elusive or as a complicated and daunting task. Photo-elicitation was a powerful tool in eliciting a diversity of perspectives that exist around the HA role and the work advocates perform; training programs might consider using visuals to augment teaching for this challenging competency.

What do you mean, 'negotiating?': Patient, physician, and healthcare professional experiences of navigating hierarchy in networks of interprofessional care.

Interprofessional collaborative practice is a phenomenon that can be fraught with power dynamics between professions, within professions, and between professionals and patients. In the literature, the dominant notion is that conflicting viewpoints and interests arising from unequal power dynamics can be resolved through negotiation. This study examined COPD patients, health professionals, and physician experiences of negotiation within 10 interprofessional collaborative COPD care teams. Physicians, patients, and healthcare professionals each had strikingly different conceptions and experiences of negotiating their perspective with other team members. Our study suggests that negotiation is an idealized notion rather than a relational process embedded in interprofessional collaborative practice. Importantly, we found that the ability and opportunity to negotiate one's perspective is heavily influenced by one's position in the workplace division of labor and professional hierarchy. We conclude that "negotiation" is only one approach among many in navigating interprofessional relations. Further, the rhetorical and ideological appeal of "negotiation" may overstate its role in interactions in interprofessional care settings, and lead to a misunderstanding of the power dynamics at play. It may be naïve to assume team members can control their situation through the competitive assertion of their individual perspective in a rational debate. Unfortunately, adopting the language of negotiation uncritically may not offer relevant solutions to structural and collective problems within a healthcare workplace.

From distress to detachment: exploring how providing care for stigmatized patients influences the moral development of medical trainees.

In acute hospital settings, medical trainees are often confronted with moral challenges and negative emotions when caring for complex and structurally vulnerable patients. These challenges may influence the long term moral development of medical trainees and have significant implications for future clinical practice. Despite the importance of moral development to medical education, the topic is still relatively under-explored. To gain a deeper understanding of moral development in trainees, we conducted a qualitative exploration of how caring for a stigmatized population influences their moral development. Data were collected from 48 medical trainees, including observational field notes, supplemental interviews, and medical documentation from inpatient units of two urban teaching hospitals in a Canadian context. Utilizing a practice-based approach which draws on constructivist grounded theory, we conducted constant comparative coding and analysis. We found that caring for stigmatized populations appeared to trigger frustration in medical trainees, which often perpetuated feelings of futility as well as avoidance behaviours. Additionally, hospital policies, the physical learning environment, variability in supervisory practices, and perceptions of judgment and mistrust all negatively influenced moral development and contributed to apathy and moral detachment which has implications for the future. Recognizing the dynamic and uncertain nature of care for stigmatized patients, and addressing the influence of structural and material factors provide an opportunity to support moral experiences within clinical training, and to improve inequities.

Ecological interchangeability: supporting team adaptive expertise in moments of disruption.

While undesirable, unexpected disruptions offer unique opportunities to enact adaptive expertise. For adaptive expertise to flourish, individuals and teams must embrace both efficiency and adaptation. While some industries do it readily, others continue to struggle with the tension between efficiency and adaptation, particularly when otherwise stable situations are unexpectedly disrupted. For instance, in healthcare settings, the efficiency mandate for strict compliance with scopes of practice can deter teams from using the adaptive strategy of making their members interchangeable. Yet, interchangeability has been hinted as a key capacity of today' teams that are required to navigate fluid team structures. Because interchangeability - as an adaptive strategy - can generate antagonistic reactions, it has not been well studied in fluid teams. Thus, in this exploratory qualitative study we sought to gain insights into how interchangeability manifests when fluid teams from five different contexts (healthcare, emergency services, orchestras, military, and business) deal with disruptive events. According to our participants, successful interchangeability was possible when people knew how to work within one's role while being aware of their teammates' roles. However, interchangeability included more than just role switching. Interchangeability took various forms and was most successful when teams capitalized on the procedural, emotional, and social dimensions of their work. To reflect this added complexity, we refer to interchangeability in fluid teams as Ecological Interchangeability. We suggest that ecological interchangeability may become a desired feature in the training of adaptive expertise in teams, if its underlying properties and enabling mechanisms are more fully understood.

On collective self-healing and traces: How can swarm intelligence help us think differently about team adaptation?

BACKGROUND: Health care teams are increasingly forced to navigate complex challenges to achieve their collective aim of delivering high-quality, safe patient care. The teamwork literature has struggled to develop strategies that promote effective adaptive behaviours among health care teams. In part, this challenge stems from the fact that truly collective adaptive behaviour requires members of the teams to abandon the human urge to act self-sufficiently. Nature contains striking examples of collective behaviour as seen in social insects, fish and bird colonies. This collective behaviour is known as Swarm Intelligence (SI). SI remains poorly described in the health care team literature and its potential benefits hidden. OBJECTIVE: In this cross-cutting edge paper, I explore the principles of SI as they pertain to systemic or collective adaptation in human teams. In particular, I consider the principles of trace-based communication and collective self-healing and what they might offer to team adaptation researchers in medical education. RESULTS: From a SI perspective, a solution to a problem emerges as a result of the collective action of the members of the swarm, not the individual action. This collective action is achieved via four principles: direct and indirect communication, awareness, self-determination and collective self-healing. Among those principles, trace-based communication and collective self-healing have been purposefully used by other industries to foster team adaptation. Trace-based communication relies on leaving 'traces' in the environment to drive the behaviour of others. Collective self-healing is the ability of the swarm to cope with failure and adapt to changes by permitting swarm members to be interchangeable. CONCLUSIONS: While allowing teams to rely on indirect communication and to be interchangeable might create discomfort to our ways of thinking, teams outside health care are demonstrating their value to advance human teamwork. SI offers a helpful analogy and a constructive language for thinking about team adaptation.

Exploring patients' and physicians' perspectives about competent health advocacy.

INTRODUCTION: Many residency programmes struggle to demonstrate how they prepare trainees to become competent health advocates. To meaningfully teach and assess it, we first need to understand what 'competent' health advocacy (HA) is and what competently enacting it requires. Attempts at clarifying HA have largely centred around the perspectives of consultant physicians and trainees. Without patients' perspectives, we risk training learners to advocate in ways that may be misaligned with patients' needs and goals. Therefore, the purpose of our research was to generate a multi-perspective understanding about the meaning of competence for the HA role. METHODS: We used constructivist grounded theory to explore patients' and physicians' perspectives about competent health advocacy. Data were collected using photo elicitation; patients (n = 10) and physicians (n = 14) took photographs depicting health advocacy that were used to inform semi-structured interviews. Themes were identified using constant comparative analysis. RESULTS: Physician participants associated HA with disruption or political activism, suggesting that competence hinged on medical and systems expertise, a conducive learning environment, and personal and professional characteristics including experience, status and political savvy. Patient participants, however, equated physician advocacy with patient centredness, perceiving that competent HAs are empathetic and attentive listeners. In contrast to patients, few physicians identified as advocates, raising questions about their ability to train or to thoughtfully assess learners' abilities. CONCLUSION: Few participants perceived HA as a fundamental physician role-at least not as it is currently defined in curricular frameworks. Misperceptions that HA is primarily disruptive may be the root cause of the HA problem; solving it may rely on focusing training on bolstering skills like empathy and listening not typically associated with the HA role. Since there may be no competency where the patient voice is more critical, we need to explore opportunities for patients to facilitate learning for the HA role.

The embodiment of practice thresholds: from standardization to stabilization in surgical education.

Surgeons practice their own variations on a procedure. Residents experience shifting thresholds between variations that one surgeon holds firmly as principle and another takes more lightly as preference. Such variability has implications for surgical education, but the impact is not well understood. This is a critical problem to investigate as programs seek to define procedures for competency-based medical education (CBME) and improve learning through deliberate practice. Our study analyzes the emergence of procedural variation in an early-adopter CBME program through a situational analysis of tonsillectomy, a foundation level procedure in this otolaryngology, head and neck surgical program. An earlier phase of the study identified frequent variations (n = 12) on tonsillectomy among co-located surgeons who routinely perform this procedure (n = 6). In the phase reported here we interviewed these surgeons (n = 4) and residents at different stages of training (n = 3) about their experiences of these variations to map the relations of contributing social and material actors. Our results show that even a basic procedure resists standardization. This study contributes a sociomaterial grounded theory of surgical practice as an embodied response to conditions materialized by intra-relations of human and more-than-human actors. Shifting root metaphors about practice in surgical education from standardization to stabilization can help residents achieve stable-for-now embodiments of performance as their practice thresholds continue to emerge.

Drawing on experience: exploring the pedagogical possibilities of using rich pictures in health professions education.

In both clinical and health professions education research, rich pictures, or participant-generated drawings of complex phenomena, are gaining recognition as a useful method for exploring multifaceted and emotional topics in medicine. For instance, two recent studies used rich pictures to augment semi-structured interviews exploring trainees', health care professionals' (HCPs), and parents' experiences of difficult conversations in the Neonatal Intensive Care Unit (NICU)-an environment in which communication is often challenging, anxiety-provoking, and emotionally distressing. In both studies, participants were invited to draw a picture depicting how they experienced a difficult conversation in this setting. As part of the interview process, participants were asked to both describe how they engaged with rich pictures, and to share their perceptions about the affordances and limitations of this research method. Here, their perspectives are reported and the possibilities of using rich pictures to inform pedagogical innovations in health professions education and research are considered.

Macro and meso level influences on distributed integrated COPD care delivery: a social network perspective.

BACKGROUND: Care guidelines for people with chronic obstructive pulmonary disease (COPD) recommend an integrated approach for holistic, flexible, and tailored interventions. Continuity of care is also emphasised. However, many patients with COPD experience fragmented care. Discontinuities in healthcare and related social services are likely to result in disjointed rather than integrated care which can negatively affect patient health outcomes. The purpose of this qualitative study was to improve our understanding of, and how, contextual features pertaining to structures and processes of COPD integrated care influence delivery of care within patients' healthcare networks. METHODS: We conducted individual interviews with 28 participants (9 patients, 16 healthcare professionals, and 3 spousal caregivers). Participants were recruited through the lung clinic at a city hospital in western Canada. We employed a social network paradigm to analyse and interpret the data. RESULTS: The analysis revealed an overarching theme of fragmented COPD care with two sub-themes: (1) Funding shortfalls and availability of resources, and (2) Dis(mis)connected communication pathways. The overarching theme depicts variations, delays, and discontinuities in patient care. The sub-themes describe how macro level influences and meso level shortfalls were perceived to influence the availability of respiratory care resources that contributed to fragmented COPD care. CONCLUSIONS: Employing a social network lens drew particular attention to family physicians' pivotal role in delivering community-based COPD care. While an integrated approach to care is recommended by care guidelines, institutional and organizational structures and processes, such as financial and communication structures, may inhibit delivery of integrated care. Thus, macro and meso level structures and processes have the potential to shape patient care by constraining family physicians' purposive and communication actions necessary for facilitating an integrated distributed approach to care. We propose a context of care which fosters a context for family physicians' delivery of patient-centered care. Integrated care delivery may improve patients' wellbeing and alleviate financial constraints on the healthcare system.

Journey into uncertainty: Medical students' experiences and perceptions of failure.

CONTEXT: Having succeeded in being selected for medical school, medical students are not always familiar with failure and yet they are expected to graduate prepared to effectively function in the failure-burdened arena of clinical medicine. Lacking in the developing literature on learners and failure is an exploration of how this transformation is accomplished. The purpose of this study was to examine how medical students perceive and experience failure during their medical school training. METHOD: We used a qualitative description methodology to probe the failure experiences of medical students attending a Canadian medical school. Participants were provided with the broad definition of failure used in this research: 'deviation from expected and desired results.'In total, 12 students were sampled, three from each of the 4 years of study, and participated in individual, semi-structured interviews that were analysed using thematic analysis to identify and describe core themes. RESULTS: At the start of medical school, students admitted limited experience with failure; their early descriptions were self-centred and binary. Personal stories recounted by preceptors encouraged students and helped them understand that physicians are human and that failure is inevitable. Students felt relatively protected from failures that could impact patients. Both witnessing and participating in a failure event were distressing and sometimes at odds with their expectations. Students expressed a desire to talk about the experience. CONCLUSIONS: Medical students described examples of experiencing failure during medical school that transported them from the more certain black and white beginnings of their classroom into the uncertain shades of grey of clinical medicine. What the participants heard, saw and experienced suggests opportunities for classroom teachers to better prepare pre-clinical students for the inevitability of failure in clinical medicine and opportunities for clinical teachers to engage in open, inclusive conversations surrounding failures that occur on their watch.

Beyond summative decision making: Illuminating the broader roles of competence committees.

CONTEXT: Although competence committees (CCs) are most often conceptualised as group decision-making bodies, policy documents forward a more ambitious vision and outline several additional roles for CCs that support the continuous quality improvement of education programmes and promote formative feedback. However, whether these functions are encompassed in the everyday work of CCs is currently unknown. METHODS: This constructivist grounded theory study elaborates the range of roles taken up by CCs and illuminates the processes through which these roles are actualised. Two investigators observed 27 CC meetings (>80 hours) across seven diverse postgraduate programmes at a single Canadian institution. Following each observation, a semi-structured interview was conducted with one CC member. Data collection and analysis unfolded iteratively. RESULTS: In this study, CCs did much more than make summative decisions about progression and entrustment; they identified a variety of problems that arose at the levels of both the individual learner and the programme, and leveraged their knowledge of assessment data to develop solutions. The problem-solving work of CCs was enabled by the in-depth data review, synthesis and analysis work that occurred before scheduled meetings, outside protected academic or administrative time. Although this work often appeared invisible to those outside the committee, the insights gleaned from data review provided committee members with essential information about how their programme of assessment was unfolding in practice. CONCLUSIONS: Competence committees may be an untapped resource that can support assessment for learning, local evaluation of competency-based medical education (CBME) implementation and continuous quality improvement for programmes of assessment. However, the ability of CCs to engage in this work is fragile and is currently sustained by the willingness of faculty members to devote their time and energy to it. The resourcing of CCs may have profound implications for translation of the theory of programmatic assessment and CBME into practice.

Trainee-environment interactions that stimulate motivation: A rich pictures study.

CONTEXT: Staying motivated when working and learning in complex workplaces can be challenging. When complex environments exceed trainees' aptitude, this may reduce feelings of competence, which can hamper motivation. Motivation theories explain how intrapersonal and interpersonal aspects influence motivation. Clinical environments include additional aspects that may not fit into these theories. We used a systems approach to explore how the clinical environment influences trainees' motivation and how they are intertwined. METHODS: We employed the rich pictures drawing method as a visual tool to capture the complexities of the clinical environment. A total of 15 trainees drew a rich picture representing a motivating situation in the workplace and were interviewed afterwards. Data collection and analysis were performed iteratively, following a constructivist grounded theory approach, using open, focused and selective coding strategies as well as memo writing. Both drawings and the interviews were used to reach our results. RESULTS: Trainees drew situations pertaining to tasks they enjoyed doing and that mattered for their learning or patient care. Four dimensions of the environment were identified that supported trainees' motivation. First, social interactions, including interpersonal relationships, supported motivation through close collaboration between health care professionals and trainees. Second, organisational features, including processes and procedures, supported motivation when learning opportunities were provided or trainees were able to influence their work schedule. Third, technical possibilities, including tools and artefacts, supported motivation when tools were used to provide trainees with feedback or trainees used specific instruments in their training. Finally, physical space supported motivation when the actual setting improved the atmosphere or trainees were able to modify the environment to help them focus. CONCLUSIONS: Different clinical environment dimensions can support motivation and be modified to create optimal motivating situations. To understand motivational dynamics and support trainees to navigate through postgraduate medical education, we need to take all clinical environment dimensions into account.

Rich pictures: a companion method for qualitative research in medical education.

CONTEXT: Within the social sciences, researchers increasingly build on visual methods to explore complex phenomena and understand how people experience and give meaning to this complexity. Amongst the variety of visual methods available, rich pictures are beginning to gain traction in health professions education (HPE) research. APPROACH: A rich picture is a pictorial representation of a particular situation, including what happened, who was involved, how people felt, how people acted, how people behaved, and what external pressures they acted upon. Rich pictures expand our perspective; they may highlight connections, illuminate the big picture and reveal unexpected emotions. Although new methods bring excitement to the field, it is our responsibility to also be cautious and insightful about their limitations. Rich pictures are a method in evolution in HPE research, with many unknowns about what is possible and what is optimal. PURPOSE: In the current paper, we aim to map out the background, describe the process and share some reflective insights of using rich pictures as a data collection method.

What is the state of complexity science in medical education research?

CONTEXT: 'Complexity' is fast becoming a 'god term' in medical education, but little is known about how scholars in the field apply complexity science to the exploration of education phenomena. Complexity science presents both opportunities and challenges to those wishing to adopt its approaches in their research, and debates about its application in the field have emerged. However, these debates have tended towards a reductive characterisation of complexity versus simplicity. We argue that a more productive discussion centres on the multiplicity of complexity orientations, with their diverse disciplinary roots, concepts and terminologies. We discuss this multiplicity and use it to explore how medical education researchers have taken up complexity science in prominent journals in the field. METHODS: We synthesised the health sciences and medical education literature based on 46 papers published in the last 18 years (2000-2017) to describe the patterns of use of complexity science in medical education and to consider the consequences of those patterns for our ability to advance scholarly conversations about 'complex' phenomena in our field. RESULTS: We identified four patterns in the use of complexity science in medical education research. Firstly, complexity science is described in a variety of ways. Secondly, multiple approaches to complexity are used in combination in single papers. Thirdly, the type of complexity science used tends to be left implicit. Fourthly, the complexity orientation used is much more commonly located using secondary source citation rather than primary source citation. CONCLUSIONS: The presence of these four patterns begs the question: Do medical education scholars understand that there are multiple legitimate orientations to complexity science, deriving from distinct disciplinary origins, drawing on different metaphors and serving distinct purposes? If we do not understand this, a cascade of potential consequences awaits. We may assume that complexity science is singular in that there is only one way to do it. This assumption may cause us to perceive our way as the 'right' way and to disregard other approaches as illegitimate. However, this perception of illegitimacy may limit our ability to enter into productive dialogue about our complexity science-inspired research.

Some assembly required: tracing the interpretative work of Clinical Competency Committees.

OBJECTIVES: This qualitative study describes the social processes of evidence interpretation employed by Clinical Competency Committees (CCCs), explicating how they interpret, grapple with and weigh assessment data. METHODS: Over 8 months, two researchers observed 10 CCC meetings across four postgraduate programmes at a Canadian medical school, spanning over 25 hours and 100 individual decisions. After each CCC meeting, a semi-structured interview was conducted with one member. Following constructivist grounded theory methodology, data collection and inductive analysis were conducted iteratively. RESULTS: Members of the CCCs held an assumption that they would be presented with high-quality assessment data that would enable them to make systematic and transparent decisions. This assumption was frequently challenged by the discovery of what we have termed 'problematic evidence' (evidence that CCC members struggled to meaningful interpret) within the catalogue of learner data. When CCCs were confronted with 'problematic evidence', they engaged in lengthy, effortful discussions aided by contextual data in order to make meaning of the evidence in question. This process of effortful discussion enabled CCCs to arrive at progression decisions that were informed by, rather than ignored, problematic evidence. CONCLUSIONS: Small groups involved in the review of trainee assessment data should be prepared to encounter evidence that is uncertain, absent, incomplete, or otherwise difficult to interpret, and should openly discuss strategies for addressing these challenges. The answer to the problem of effortful processes of data interpretation and problematic evidence is not as simple as generating more data with strong psychometric properties. Rather, it involves grappling with the discrepancies between our interpretive frameworks and the inescapably subjective nature of assessment data and judgement.

Engagement: what is it good for? The role of learner engagement in healthcare simulation contexts.

Learner engagement matters, particularly in simulation-based education. Indeed, it has been argued that instructional design only matters in the service of engaging learners in a simulation encounter. Yet despite its purported importance, our understanding of what engagement is, how to define it, how to measure it, and how to assess it is limited. The current study presents the results of a critical narrative review of literature outside of health sciences education, with the aim of summarizing existing knowledge in these areas and providing a research agenda to guide future scholarship on learner engagement in healthcare simulation. Building on this existing knowledge base, we provide a working definition for engagement and provide an outline for future research programs that will help us better understand how health professions' learners experience engagement in the simulated setting. With this in hand, additional research questions can be addressed including: how do simulation instructional design features (fidelity, range of task difficulty, feedback, etc.) affect engagement? What is the relationship between engagement and simulation learning outcomes? And how is engagement related to or distinct from related variables like cognitive load, motivation, and self-regulated learning?

Pimping in Residency: The Emotional Roller-Coaster of a Pedagogical Method - A Qualitative Study Using Interviews and Rich Picture Drawings.

Phenomenon: Pimping has become a well-known and distinct form of questioning in medical education, and as a pedagogical method it has both proponents and detractors. Pimping occurs when a teacher (pimper) asks difficult questions of the learner (pimpee), usually in rapid succession. There is a paucity of literature formally studying this technique and its effects on teachers and learners. Our study examines the use of and attitudes toward pimping in a pathology residency program to better understand its perceived value and effectiveness. Approach: Using a qualitative approach, we conducted semistructured interviews with 8 pathology trainees and 9 pathologists. As part of the interview process, we asked participants to draw a rich picture of a pimping encounter. Consistent with this qualitative method, we analyzed data iteratively using constant comparison. Findings: Negative emotions including anxiety and self-doubt dominated among the learners during pimping encounters. For some, these resulted in motivation to study, and for others this was a futile, nonmotivating experience. Most trainees felt that they were being judged during pimping; however, they perceived that the intentions of pimping were not malicious and in their best interests. This was supported by pathologists, who stated that their motivation for pimping was to identify knowledge gaps, thus benefiting the trainee. Insights: Pimping created a dichotomy of emotions within the majority of learners in this study. Negative emotions occurred during pimping encounters; however, following the encounter, pimping was perceived in a more positive light. Recognizing when and how pimping can create negative emotions that may interfere with learning may enable educators to create more consistently meaningful interactions.