The “things themselves”: challenging heuristics and inciting empathy via Husserlian phenomenology Abstract I propose that the phenomenology of Edmund Husserl provides a meaningful mode of access to the patient experience. By reflecting on a real-life encounter with grief, my own medical training, and two works of literature, Nausea and Love in the Time of Cholera, I illustrate the application of philosophy and specifically phenomenology to clinical education. Phenomenology allows clinicians to strip away assumptions, habits of thinking, and normative ideas within the clinical encounter in order to enter the descriptive world of the patient. In suspending presuppositions and heuristics, the clinician can better empathize with the vivid, embodied stories that the patient is describing. Finally, the practice of phenomenology makes tangible the complexities of medical illnesses, emotions, and lived experiences.

Assessment in the context of problem-based learning Abstract Arguably, constructive alignment has been the major challenge for assessment in the context of problem-based learning (PBL). PBL focuses on promoting abilities such as clinical reasoning, team skills and metacognition. PBL also aims to foster self-directed learning and deep learning as opposed to rote learning. This has incentivized researchers in assessment to find possible solutions. Originally, these solutions were sought in developing the right instruments to measure these PBL-related skills. The search for these instruments has been accelerated by the emergence of competency-based education. With competency-based education assessment moved away from purely standardized testing, relying more heavily on professional judgment of complex skills. Valuable lessons have been learned that are directly relevant for assessment in PBL. Later, solutions were sought in the development of new assessment strategies, initially again with individual instruments such as progress testing, but later through a more holistic approach to the assessment program as a whole. Programmatic assessment is such an integral approach to assessment. It focuses on optimizing learning through assessment, while at the same gathering rich information that can be used for rigorous decision-making about learner progression. Programmatic assessment comes very close to achieving the desired constructive alignment with PBL, but its wide adoption—just like PBL—will take many years ahead of us.

Statistics 101

Incorporating content related to value and cost-considerations in clinical decision-making: enhancements to medical education Abstract Although incorporating cost-considerations during healthcare decision-making is increasingly important to American patients and physicians, content related to these constructs is not routinely included in medical education. As a result, physicians are ill-equipped to consider costs. This study sought input from practicing physicians on perceived deficiencies in current teaching and recommendations for necessary content to include in medical teaching. We conducted a qualitative descriptive study using semi-structured interviews utilizing a purposeful maximum variation sample of cardiologists and neonatologists practicing in diverse settings. We analyzed interviews using conventional content analysis. 18 cardiologists and 17 neonatologists participated in this study. Respondents perceived that current teaching does not impart sufficient knowledge of value and cost considerations to achieve patient-centered, high-value decision-making. They identified the following priority areas for education related to healthcare costs: the business of medicine and information about out-of-pocket patient costs, training in health research interpretation skills to critically appraise evidence, and communication skills to engage patients as partners in shared decision-making. Participants recommended a variety of teaching methods, including didactic sessions on core topics, role modeling and case studies. American physicians perceive learning needs related to the incorporation of costs into clinical decision-making that can inform curriculum development initiatives in this field. Physicians perceive knowledge of these topics and skills to be crucial to achieving patient-centered high-value care. Concomitant health system reforms supporting the needs of the patient at its center are essential to enable physicians to focus on a patient-centered approach to healthcare delivery.

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

Learning to interact and interacting to learn: a substantive theory of clinical workplace learning for diverse cohorts Abstract Social interactions are integral to clinical workplace functioning and are recognised to play an important role in clinical workplace learning. How, why and to what end students, in the context of today’s culturally and linguistically diverse cohorts, interact with members of clinical workplace communities during clinical workplace learning is not well understood. The aim of this research was to generate a theoretical understanding of students’ interactive processes in clinical workplace learning that accounted for high levels of cultural/linguistic diversity. In accordance with constructivist grounded theory methods, data collection and analysis were premised on theoretical sampling and constant comparative analysis, and undertaken from an informed and reflexive stance. This involved iterations of survey, interview and diary data from two diverse cohorts of final year veterinary students who had undergone 11 months of clinical workplace learning. Clinical preceptors were also interviewed. As an aid to theory building, testing and refinement, and in order to test the theory’s relevance, usefulness and transferability beyond veterinary clinical education, critical feedback was sought from medical and allied health educators. Our substantive level theory demonstrates that upon entering the clinical workplace community, students learn how to ‘harness dialogue’ in order to effectively coordinate three, inter-related interactive processes: (i) functioning in the workplace, (ii) impression management and (iii) learning-in-the-moment. We found both positive and negative consequences ensued, depending on how students harnessed dialogue. The theory responds to a perceived need in international student education to move away from a deficit discourse by developing educational theory which focuses on the nature of participation, rather than the nature of the student.

Examining grounded theory through the lens of rationalist epistemology Abstract The objective of scientific, or more broadly, academic knowledge is to provide an understanding of the social and natural world that lies beyond common sense and everyday thinking. Academics use an array of techniques, methods and conceptual apparatuses to achieve this goal. The question we explore in this essay is the following: Does the grounded theory approach, in the constructivist version developed by Kathy Charmaz, provide the necessary methodological tools for the creation of knowledge and theories beyond everyday thinking? To conduct our analysis, we have drawn on the rationalist epistemology originally developed by Gaston Bachelard and taken up a few decades later by Pierre Bourdieu and colleagues to look at the epistemological foundation of the CGT methods as defined by Charmaz. We focussed on two distinctive epistemological features characterising constructivist grounded theory (CGT): the use of inductive reasoning to generate interpretative theory; and the primacy of subjectivity over objectivity as the preferred path to knowledge making. While the usefulness of CGT for conducting qualitative research and understanding the perspective of social actors has been acknowledged by scholars in health professions education research and other research areas, the inductivist logic on which it draws raises questions concerning the nature of the knowledge yielded by this approach. As we argue in this article, it is still unclear in what way the interpretative theory generated by CGT is not a duplication of everyday thinking expressed through meta-narratives. It is also unclear how the understanding of social phenomena can be refined if the use of inductive procedures logically implies the creation of a new theory each time a study is conducted. We engage with these questions to broaden the epistemological conversation within the health professions education research community. It is our hope that scholars in the field will engage in this epistemological conversation and advance it in new directions.

“My right-hand man” versus “We barely make use of them”: change leaders talking about educational scientists in curriculum change processes—a Membership Categorization Analysis Abstract Health professions education scholarship units (HPESUs) are increasingly becoming a standard for medical schools worldwide without having much information about their value and role in actual educational practices, particularly of those who work in these units, the educational scientists. We conducted a linguistic analysis, called Membership Categorization Analysis, of interviews with leaders of recent curriculum changes to explore how they talk about educational scientists in relation to these processes. The analysis was conducted on previously collected interview data with nine change leaders of major undergraduate medical curriculum change processes in the Netherlands. We analyzed how change leaders categorize HPESUs and educational scientists (use of category terms) and what they say about them (predicates). We noticed two ways of categorizing educational scientists, with observable different predicates. Educational scientists categorized by their first name were suggested to be closer to the change process, more involved in decisional practices and positively described, whereas those described in more generic terms were represented in terms of relatively passive and unspecified activities, were less explicit referenced for their knowledge and expertise and were predominantly factually or negatively described. This study shows an ambiguous portrayal of educational scientists by leaders of major curriculum change processes. Medical schools are challenged to establish medical curricula in consultation with a large, diverse and interdisciplinary stakeholder group. We suggest that it is important to invest in interpersonal relationships to strengthen the internal collaborations and make sure people are aware of each other’s existence and roles in the process of curriculum development.

Comfort with uncertainty: reframing our conceptions of how clinicians navigate complex clinical situations Abstract Learning to take safe and effective action in complex settings rife with uncertainty is essential for patient safety and quality care. Doing so is not easy for trainees, as they often consider certainty to be a necessary precursor for action and subsequently struggle in these settings. Understanding how skillful clinicians work comfortably when uncertain, therefore, offers an important opportunity to facilitate trainees’ clinical reasoning development. This critical review aims to define and elaborate the concept of ‘comfort with uncertainty’ in clinical settings by juxtaposing a variety of frameworks and theories in ways that generate more deliberate ways of thinking about, and researching, this phenomenon. We used Google Scholar to identify theoretical concepts and findings relevant to the topics of ‘uncertainty,’ ‘ambiguity,’ ‘comfort,’ and ‘confidence,’ and then used preliminary findings to pursue parallel searches within the social cognition, cognition, sociology, sociocultural, philosophy of medicine, and medical education literatures. We treat uncertainty as representing the lived experience of individuals, reflecting the lack of confidence one feels that he/she has an incomplete mental representation of a particular problem. Comfort, in contrast, references confidence in one’s capabilities to act (or not act) in a safe and effective manner given the situation. Clinicians’ ‘comfort with uncertainty’ is informed by a variety of perceptual, emotional, and situational cues, and is enabled through a combination of self-monitoring and forward planning. Potential implications of using ‘comfort with uncertainty’ as a framework for educational and research programs are explored.

First-year medical students’ calibration bias and accuracy across clinical reasoning activities Abstract To be safe and effective practitioners and learners, medical professionals must be able to accurately assess their own performance to know when they need additional help. This study explored the metacognitive judgments of 157 first-year medical students; in particular, the study examined students’ self-assessments or calibration as they engaged in a virtual-patient simulation targeting clinical reasoning practices. Examining two key subtasks of a patient encounter, history (Hx) and physical exam (PE), the authors assessed the level of variation in students’ behavioral performance (i.e., effectiveness and efficiency) and judgments of performance (i.e., calibration bias and accuracy) across the two subtasks. Paired t tests revealed that the Hx subtask was deemed to be more challenging than the PE subtask when viewed in terms of both actual and perceived performance. In addition to students performing worse on the Hx subtask than PE, they also perceived that they performed less well for Hx. Interestingly, across both subtasks, the majority of participants overestimated their performance (98% of participants for Hx and 95% for PE). Correlation analyses revealed that the participants’ overall level of accuracy in metacognitive judgments was moderately stable across the Hx and PE subtasks. Taken together, findings underscore the importance of assessing medical students’ metacognitive judgments at different points during a clinical encounter.