The Question of Competence: Reconsidering Medical Education in the Twenty-First Century

[Excerpt] The real challenge for those involved in designing competency-based educational programs is to recognize the complexity of competence as a concept. Only then can they effectively delineate the knowledge, skills, and attitudes that learners must acquire to be able to perform within each domain at a predetermined level and to recognize that the expected level of performance within each domain will vary depending on the learner\u27s stage of education and the specialty he or she is learning. The authors of this book help us do just that. They examine the challenges facing medical education and introduce the concept of discourse as a mechanism both for examining the idea of competence and considering how to implement competency-based education. In so doing, they provide us with a new way to ask the questions that are at the heart of every report advocating change, every criticism of medical education, and every conversation that questions why health care is the way it is today

Exploring the experiences of Canadian medical students with a background in the arts and humanities

Background: Arts and Humanities (A/H) training is a powerful strategy to help medical students develop key competencies which align with the CanMEDS roles that Canadian physicians are expected to embody. Students with backgrounds in A/H may enter medical school with the skills and dispositions that A/H training provides. This paper explores the varied experiences of medical students with prior A/H backgrounds, with an emphasis on how they navigate relationships with their student cohorts and participate in undergraduate medical training environments. Methods: Descriptive qualitative research methodology was used to conduct and analyze semi-structured interviews exploring the perspectives of Canadian medical students with either a A/H degree or training in A/H (n = 13). Domains such as identity, integration of interests, and challenges in maintaining A/H interests during medical training were explored. Results: Participants described their A/H identity as intertwined with their identity as medical trainees and described their sense of interconnection between the disciplines. Challenges included imposter syndrome and difficulties in relating with peers from science backgrounds. Participants described returning to their A/H interests as a tool for wellness amidst medical training. Conclusions: Medical students with a background in A/H training describe this background as offering both affordances and challenges for their sense of identity, belonging, and wellness. These students offer an untapped resource: they come with dispositions of value to medicine, and they perceive a positive, hidden A/H curriculum that supports their maintenance of these dispositions during training. Understanding more about these hidden treasures could help foster the development of well-rounded and humanistic physicians in the entire medical class

What about Happiness? A Critical Narrative Review with Implications for Medical Education.

INTRODUCTION Despite abundant scholarship and improvement initiatives, the problem of physician wellbeing persists. One reason might be conceptual: the idea of 'happiness' is rare in this work. To explore how it might influence the conversation about physician wellbeing in medical education, we conducted a critical narrative review asking: 'How does happiness feature in the medical education literature on physician wellbeing at work?' and 'How is happiness conceptualized outside medicine?' METHODS Following current methodological standards for critical narrative review as well as the Scale for the Assessment of Narrative Review Articles, we conducted a structured search in health research, humanities and social sciences, a grey literature search, and consultation with experts. After screening and selection, content analysis was performed. RESULTS Of 401 identified records, 23 were included. Concepts of happiness from the fields of psychology (flow, synthetic happiness, mindfulness, flourishing), organizational behaviour (job satisfaction, happy-productive worker thesis, engagement), economics (happiness industry, status treadmill), and sociology (contentment, tyranny of positivity, coercive happiness) were identified. The medical education records exclusively drew on psychological concepts of happiness. DISCUSSION AND CONCLUSION This critical narrative review introduces a variety of conceptualizations of happiness from diverse disciplinary origins. Only four medical education papers were identified, all drawing from positive psychology which orients us to treat happiness as individual, objective, and necessarily good. This may constrain both our understanding of the problem of physician wellbeing and our imagined solutions. Organizational, economical and sociological conceptualizations of happiness can usefully expand the conversation about physician wellbeing at work

Why open-ended survey questions are unlikely to support rigorous qualitative insights

Health professions education researchers are increasingly relying on a combination of quantitative and qualitative research methods to explore complex questions in the field. This important and necessary development, however, creates new methodological challenges that can affect both the rigor of the research process and the quality of the findings. One example is qualitatively analyzing free-text responses to survey or assessment instrument questions. In this Invited Commentary, the authors explain why analysis of such responses rarely meets the bar for rigorous qualitative research. While the authors do not discount the potential for free-text responses to enhance quantitative findings or to inspire new research questions, they caution that these responses rarely produce data rich enough to generate robust, stand-alone insights. The authors consider exemplars from health professions education research and propose strategies for treating free-text responses appropriately

To stay or not to stay? a grounded theory study of residents\u27 postcall behaviors and their rationalizations for those behaviors

PURPOSE: Although policies to restrict residents\u27 duty hours are pervasive, resident adherence to restricted duty hours has proved challenging. The authors sought to describe residents\u27 postcall behaviors and understand the dominant rationalizations underpinning their decisions to stay or not to stay after a 24-hour shift. METHOD: Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 24 residents across six surgical and nonsurgical specialty programs at one Canadian institution during 2012. They analyzed transcripts iteratively using a constant comparative method of identifying and refining key themes as the data set accrued, and theoretically sampling until theme saturation. RESULTS: Abiding by cultural norms was the dominant rationalization for both choosing to continue to work postcall or to go home. Cutting across this dominant theme were three subcategories (infrastructure, invoking values, and negotiating tension) with a pattern of residents invoking similar values of patient safety and education regardless of the cultural norms of their program, the infrastructure within which they worked, or the tensions they were navigating. CONCLUSIONS: Although central to residents\u27 rationalizations, values appear to be versatile, amenable to multiple, even conflicting, applications. Residents perceived that they were upholding the values of patient safety and education regardless of which postcall behavior they chose - staying or going. Based on this, for duty hours reform initiatives to be successful, a shift to emphasizing organizational changes will be required to reduce the circumstances in which postcall behavior is an individual, values-based decision

Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016

The Surgical Safety Checklist (SSC) was implemented as part of the World Health Organization’s Safer Surgery saves lives campaign. The SSC and its reported positive influence in the operating room was first published in 2008. Since then, this positive perception has changed. New research has identified mixed results showing limited or no change in outcomes following SSC implementation. Such research has prompted calls for the reconsideration of policies mandating the SSC as an organisational safety practice. In the context of this debate, the purpose of this narrative review was to evaluate how knowledge about SSC has been represented and reconstructed in high impact SSC papers. We used the h-index to identify highly impactful articles published between 2009 and 2016. We analysed these articles using three criteria that emerged as we reviewed them: 1) Whether the SSC was conceptualized as a ‘thing’ or a ‘process’, 2) Whether the SSC problem and solution were characterized as straightforward or complex issues and, 3) How the SSC knowledge was reconstructed from one paper to the next. We found that many papers in the sample exhibited a pattern of simplifying the story of SSC from earlier work, even when that work may itself have discussed a more nuanced characterization of SSC. This simplicity suggests that knowledge has not been mobilizing effectively across this body of work. We conclude that knowledge mobilization would be improved with a new generation of SSC research that particularly explores and enhances our understanding of the socio-cultural nuances of SSC practices

The rules of the game: interprofessional collaboration on the intensive care unit team

BACKGROUND: The intensive care unit (ICU) is a nexus for interspecialty and interdisciplinary tensions because of its pivotal role in the care of the hospital's most critically ill patients and in the management of critical care resources. In an environment charged with temporal, financial and professional tensions, learning how to get results collaboratively is a critical aspect of professional competence. This study explored how team members in the ICU interact to achieve daily clinical goals, delineate professional boundaries and negotiate complex systems issues. METHODS: Seven 1-hour focus groups were conducted with ICU team members in two hospitals. Participants consisted of four nursing groups (n = 27), two resident groups (n = 6) and one intensivist group (n = 4). Interviews were audio-recorded, anonymized and transcribed. With the use of a standard qualitative approach, transcripts were analyzed iteratively for recurrent themes by four researchers. RESULTS: Team members articulated their perceptions of the mechanisms by which team collaboration was achieved or undermined in a complex and high-pressure context. Two mechanisms were recurrently described: the perception of 'ownership' and the process of 'trade'. Analysis of these mechanisms reveals how power is commodified, possessed and exchanged as team members negotiate their daily needs and goals with one another. CONCLUSION: Our data provide a non-idealized depiction of how health care professionals function on a team so as to meet both individual and collective goals. We contend that the concept of 'team' must move beyond the rhetoric of 'cooperation' and towards a more authentic depiction of the skills and strategies required to function in the competitive setting of the interprofessional health care team

(Re)Grounding Grounded Theory: A Close Reading of Theory in Four Schools

The debate over what counts as theory has dominated methodological conversations in grounded theory research for decades. Four of the schools of thought in that debate – Glaserian, Straussian, Charmazian, and Clarkeian – hold different assumptions about what theory is and how it is made. The first two schools understand theory as an abstraction that exactingly accounts for exceptions. The second two schools understand theory as a process of describing voices hidden from public view. While Glaserian and Straussian coding processes focus on coding exceptions, Charmazian and Clarkeian coding processes focus on building a story of the participants or social phenomenon. This article attempts to clarify the goals of the schools in an effort to overcome the debate about which kinds of research count as grounded theory and which do not

Perseverance, faith and stoicism: a qualitative study of medical student perspectives on managing fatigue

CONTEXT: Fatigue risk management (FRM) strategies offer a potential solution to the widespread problem of fatigued trainees in the clinical workplace. These strategies assume a shared perception that fatigue is hazardous. Despite the growing body of evidence suggesting that fatigue leads to burnout and medical errors, previous research suggests that residents perceive fatigue as a personal, surmountable burden rather than an occupational hazard. Before we can implement FRM, we need a better understanding of when and how such problematic notions of fatigue are adopted by medical trainees. Thus, we sought to explore how third-year medical students understand and manage the workplace fatigue they experience during their first year of clinical rotations. METHODS: A total of 22 third-year medical students participated in semi-structured interviews exploring their perspectives of workplace fatigue. Data collection and analysis occurred iteratively in keeping with constructivist grounded theory methodology and were informed by theoretical sampling to sufficiency. RESULTS: Our participants described unprecedented levels of sleep deprivation combined with uncertainty and confusion that led to significant fatigue during training. Drawing on their workplace experience, trainees believed that fatigue posed three distinct threats, which evoked different coping strategies: (i) threat to personal health, managed by perseverance; (ii) threat to patients, managed by faith in the system, and (iii) threat to professional reputation, managed by stoicism. CONCLUSIONS: Our findings highlight how senior medical students grapple with fatigue, as they understand it, within a training context in which they are expected to deny the impact of their fatigue on patients and themselves. Despite empirical evidence to the contrary, the prevailing assumption amongst our participants is that an ability to withstand sleep deprivation without impairment will develop naturally over time. Efforts to implement FRM strategies will need to address this assumption if these strategies are to be successfully taken up and effective

'How would you call this in English?' Being reflective about translations in international, cross-cultural qualitative research

INTRODUCTION: Medical education researchers increasingly collaborate in international teams, collecting data in different languages and from different parts of the world, and then disseminating them in English-language journals. Although this requires an ever-present need to translate, it often occurs uncritically. With this paper we aim to enhance researchers’ awareness and reflexivity regarding translations in qualitative research. METHODS: In an international study, we carried out interviews in both Dutch and English. To enable joint data analysis, we translated Dutch data into English, making choices regarding when and how to translate. In an iterative process, we contextualized our experiences, building on the social sciences and general health literature about cross-language/cross-cultural research. RESULTS: We identified three specific translation challenges: attending to grammar or syntax differences, grappling with metaphor, and capturing semantic or sociolinguistic nuances. Literature findings informed our decisions regarding the validity of translations, translating in different stages of the research process, coding in different languages, and providing ‘ugly’ translations in published research reports. DISCUSSION: The lessons learnt were threefold. First, most researchers, including ourselves, do not consciously attend to translations taking place in international qualitative research. Second, translation challenges arise not only from differences in language, but also from cultural or societal differences. Third, by being reflective about translations, we found meaningful differences, even between settings with many cultural and societal similarities. This conscious process of negotiating translations was enriching. We recommend researchers to be more conscious and transparent about their translation strategies, to enhance the trustworthiness and quality of their work