Contextualised reflective competence: a new learning model promoting reflective practice for clinical training

Background Reflection is a metacognitive process that allows self-regulation and the promotion of lifelong learning, and is an essential requirement to develop therapeutic relationships with patients and colleagues, as well as professional expertise. The medical literature is lacking on guidance for learners and educators to develop reflective abilities. Methods Based on our program of research into junior doctors delivering open disclosure communication after medical error, we developed a framework called contextualised reflective competence, to assist students/trainees and educators in developing, maintaining, and ensuring reflective practice in the context of professional experiences. Results The contextualised reflective competence framework has its origins in the conscious competency framework, an established learning paradigm within healthcare professions education, and it has been developed to encompass some of the vital concepts that the conscious competency matrix was lacking: the promotion of ongoing reflection practice, accurate assumptions of the learner’s original mindset, variations in everyday performance, and erosion of skills. The contextualised reflective competence framework progresses the conscious competence framework from a 2x2 box diagram to a two-pronged flowchart. In our framework, if the learner possesses appropriate reflective practice, contextualised reflective competence, they move through alearning process where they achieve unconscious competence. If the learner does not possess contextualised reflective competence, they move though a learning process where this display generalised reflective incompetence, characterised by cognitive dissonance and rationalisation, leading to errors and non-learning. Generalised reflective incompetence is usually a temporary state with appropriate supervision. Our program of research demonstrated that contextualised reflective competence was related to critical cognitive frameworks, such as intellectual humility, situational awareness, the development of a ‘growth mindset’, and belongingness. Conclusions The Contextualised Reflective Competence framework promotes learners’ understanding of their core competencies and provides opportunities for personal critical reflection. It provides educators and supervisors with a diagnostic pathway for those with reflective incompetence. We anticipate its use in the clinical environment where issues of competence are raised in professional experiences

Phenomenological study of medical interns reflecting on their experiences, of open disclosure communication after medication error: linking rationalisation to the conscious competency matrix

Introduction and objectives Errors are common within healthcare, especially those involving the prescribing of medications. Open disclosure is a policy stating doctors should apologise for such errors, discussing them with the harmed parties. Many junior doctors take part in open disclosure without any formal training or experience, which can lead to failure of the apology, and increased patient/family frustration. In this study, we explore the ways in which interns perceive the relationship between medication error and their experience of open disclosure. Methods Using known theoretical frameworks of apology and moral rationalisation, a qualitative study of medical interns who had been involved in open disclosure was conducted. Twelve medical interns volunteered, and were selected using purposive sampling. Face-to-face semi-structured interviews illuminated their clinical experiences of open disclosure after medication error. The data was coded and analysed using Interpretative Phenomenological Analysis. Our data supported three super-ordinate themes: (1) Rationalisation of medical error, (2) Culture of medical error and (3) Apology in practice. Results The interns in this study rationalised their observations, their subsequent actions and their language. Rather than reframing their thinking, they became part of a healthcare environment that culturally accepted, promoted and perpetuated error. Rationalisation can lead to loss of context in apologising, which can be perceived as unempathic by the patients/families. However, when reflection and unpacking of their errors, they acknowledged that their reasoning was problematic, recognised the reasons why and were able to reframe their approach to apology for a future occasion. Conclusion Our data suggests the utility of a learning framework around open disclosure following medication error, for having a supervisor conversation about aspects of the interns’ rationalisation of their clinical practice, in their contextualised clinical environment. Further research could clarify whether interns are ‘unconsciously incompetent’ or ‘consciously incompetent’, when addressing medication error and preparing to apologise

Designing health professional education curricula using systems thinking perspectives

Background Medical students navigate complex personal learning pathways from entry into medical school, through an educational program, and into life-long practice. However, many stakeholders have called for substantive reforms in contemporary curricula, citing concerns about the lack of key abilities amongst newly graduated doctors to work in complex healthcare environments. Despite the need for educators to focus on curricula design, there is a paucity of overarching perspectives that allow synthesis of the various curricular elements in a way that lends meaningfulness and appreciation to the students in terms of navigating the immediate program requirements and beyond. Without such guidance, educators risk creating fragmented program designs that can lead to both unintended and unactionable outcomes for students as well as curriculum designers. Using systems thinking, we set out to address this gap by providing an overarching perspective for curriculum designers to appreciate the relationships and the interactions of the various curricular elements that inform and impact student’s preparedness for practice. Methods By framing a curriculum as a complex adaptive system, we used soft systems thinking to develop an initial prototype of a conceptual curricular toolkit, underpinned by an appraisal of relevant literature within health professional education and the broader educational context. The prototype was further refined iteratively after critical reflection by the authors with a diverse range of national and international colleagues via posters, short communications, and workshops at several conferences, and through social media. Results We describe how the 3P-6Cs toolkit captures a learner’s personal journey through an educational program into a field of practice by logically linking the three key elements: the personal, the program, and the practice. We demonstrate its application in three examples related to contemporary health profession education curricula. These are: creating integrated educational designs to capture students’ developmental continua, conceptualising immersive clinical placements in non-traditional settings, and complexity-consistent evaluation of curricular interventions. Conclusion Applying the 3P-6Cs curricular toolkit to problems of curricula (re)design can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within education programs can inform and impact student’s preparation for lifelong practice

Quantum limits on phase-shift detection using multimode interferometers

Fundamental phase-shift detection properties of optical multimode interferometers are analyzed. Limits on perfectly distinguishable phase shifts are derived for general quantum states of a given average energy. In contrast to earlier work, the limits are found to be independent of the number of interfering modes. However, the reported bounds are consistent with the Heisenberg limit. A short discussion on the concept of well-defined relative phase is also included.Comment: 6 pages, 3 figures, REVTeX, uses epsf.st

Polarization quantum properties in type-II Optical Parametric Oscillator below threshold

We study the far field spatial distribution of the quantum fluctuations in the transverse profile of the output light beam generated by a type II Optical Parametric Oscillator below threshold, including the effects of transverse walk-off. We study how quadrature field correlations depend on the polarization. We find spatial EPR entanglement in quadrature-polarization components: For the far field points not affected by walk-off there is almost complete noise suppression in the proper quadratures difference of any orthogonal polarization components. We show the entanglement of the state of symmetric intense, or macroscopic, spatial light modes. We also investigate nonclassical polarization properties in terms of the Stokes operators. We find perfect correlations in all Stokes parameters measured in opposite far field points in the direction orthogonal to the walk-off, while locally the field is unpolarized and we find no polarization squeezing.Comment: 16 pages, 18 figure

Prospective Registry Trial Assessing the Use of Magnetic Seeds to Locate Clipped Nodes After Neoadjuvant Chemotherapy for Breast Cancer Patients

Background Targeted axillary dissection (TAD) involves locating and removing both clipped nodes and sentinel nodes for assessment of the axillary response to neoadjuvant chemotherapy (NAC) by clinically node-positive breast cancer patients. Initial reports described radioactive seeds used for localization, which makes the technique difficult to implement in some settings. This trial was performed to determine whether magnetic seeds can be used to locate clipped axillary lymph nodes for removal. Methods This prospective registry trial enrolled patients who had biopsy-proven node-positive disease with a clip placed in the node and treatment with NAC. A magnetic seed was placed under ultrasound guidance in the clipped node after NAC. All the patients underwent TAD. Results Magnetic seeds were placed in 50 patients by 17 breast radiologists. All the patients had successful seed placement at the first attempt (mean time for localization was 6.1 min; range 1-30 min). The final position of the magnetic seed was within the node (n = 44, 88%), in the cortex (n = 3, 6%), less than 3 mm from the node (n = 2, 4%), or by the clip when the node could not be adequately visualized (n = 1, 2%). The magnetic seed was retrieved at surgery from all the patients. In 49 (98%) of the 50 cases, the clip and magnetic seed were retrieved from the same node. Surgeons rated the transcutaneous and intraoperative localization as easy for 43 (86%) of the 50 cases. No device-related adverse events occurred. Conclusions Localization and selective removal of clipped nodes can be accomplished safely and effectively using magnetic seeds

Quantum properties of transverse pattern formation in second-harmonic generation

We investigate the spatial quantum noise properties of the one dimensional transverse pattern formation instability in intra-cavity second-harmonic generation. The Q representation of a quasi-probability distribution is implemented in terms of nonlinear stochastic Langevin equations. We study these equations through extensive numerical simulations and analytically in the linearized limit. Our study, made below and above the threshold of pattern formation, is guided by a microscopic scheme of photon interaction underlying pattern formation in second-harmonic generation. Close to the threshold for pattern formation, beams with opposite direction of the off-axis critical wave numbers are shown to be highly correlated. This is observed for the fundamental field, for the second harmonic field and also for the cross-correlation between the two fields. Nonlinear correlations involving the homogeneous transverse wave number, which are not identified in a linearized analysis, are also described. The intensity differences between opposite points of the far fields are shown to exhibit sub-Poissonian statistics, revealing the quantum nature of the correlations. We observe twin beam correlations in both the fundamental and second-harmonic fields, and also nonclassical correlations between them.Comment: 18 pages, 17 figures, submitted to Phys. Rev.

Level densities and γ\gamma-strength functions in 148,149^{148,149}Sm

The level densities and $\gamma$-strength functions of the weakly deformed $^{148}$Sm and $^{149}$Sm nuclei have been extracted. The temperature versus excitation energy curve, derived within the framework of the micro canonical ensemble, shows structures, which we associate with the break up of Cooper pairs. The nuclear heat capacity is deduced within the framework of both the micro canonical and the canonical ensemble. We observe negative heat capacity in the micro canonical ensemble whereas the canonical heat capacity exhibits an S-shape as function of temperature, both signals of a phase transition. The structures in the $\gamma$-strength functions are discussed in terms of the pygmy resonance and the scissors mode built on exited states. The samarium results are compared with data for the well deformed $^{161,162}$Dy, $^{166,167}$Er and $^{171,172}$Yb isotopes and with data from (n,$\gamma$)-experiments and giant dipole resonance studies.Comment: 12 figure

Peer review in team-based learning: influencing feedback literacy

Background Peer review in Team-based learning (TBL) exists for three key reasons: to promote reflection on individual behaviours; provide opportunities to develop professional skills; and prevent ‘free riders’ who fail to contribute effectively to team discussions. A well-developed process that engages students is needed. However, evidence suggests it remains a difficult task to effectively incorporate into TBL. The purpose of this study was to assess medical students’ ability to provide written feedback to their peers in TBL, and to explore students’ perception of the process, using the conceptual framework of Biggs ‘3P model’. Methods Year 2 students (n = 255) participated in peer review twice during 2019. We evaluated the quality of feedback using a theoretically derived rubric, and undertook a qualitative analysis of focus group data to seek explanations for feedback behaviors. Results Students demonstrated reasonable ability to provide positive feedback, but were less prepared to identify areas for improvement. Their ability did not improve over time, and was influenced by the perceived task difficulty; social discomfort; and sense of responsibility in providing written feedback. Conclusions To increase student engagement, we require a transparent process that incorporates verbal feedback and team discussion, with monitoring of outcomes by faculty and adequate training